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SPRING 2004 

..»>«•• *>»^ 

\ ^' 


^ *•• 


When the land failed to yield 
a mineral precious to health, 
one man's vision replenished 
soil, water, and hope. 




Alice HamiN^^^^^^^^^^^Wie 
study of diseases of thie workplace, 
a social justice activist, and a 
founder of industrial toxicology in 
tfie United States — became ttie first 
woman to join Harvard Medical 
Scfiool's faculty when she was 
appointed assistant professor in 
1919. She is pictured here the year 
she graduated from the University 
of Michigan Medical School, at 
the age of 24. 


'RING 2004 • \ O L U M E 77, NUMBER 




Letters 3 

Pulse 5 

The Second Year Show; continuing 
medical education online; the new 
Harvard Stem Cell Institute; U.S. News 
and World Report rankings; a medical 
mission to Iran in the aftermath of the 
Bam earthquake; Match Day 2004 

President's Report 12 

by Excj. Hi^inbotham 

Bookshelf 13 

Benchmarks 14 

Fatty acid imbalance emerges as a new 
clue in the fight against cystic fibrosis. 

Class Notes 56 

Obituaries 61 

Cover photograph: A young Kyrgyz 
bride awaits her wedding in the 
Xinjiang Uighur Autonomous Region 
of China, where as many as one in ten 
children suffer from the debilitating 
symptoms of severe iodine deficiency 
disorders. (Nevada Wier.^Corbis) 

Water Under the Bridge 16 

A neurologist turns to hydrology, agronomy, and veterinary medicine 
to tackle the world's most pre\'entable cause of mental retardation. 

by G O R D O N W O R L E Y 

Pickwick Revisited 24 

The sharp clinical eye of Charles Dickens inspired a physicianly 
borrowing — and sparked the imaginations of researchers dedicated 
to unraveling the mysteries of sleep disorders. 

b V P E T E R V . T I S H L E R 

Initiation Rites 32 

A ph)'sician and the Navajo community she serves struggle to make 
sense of each other's blessings and imperfections. 

b_V E L L E N L . R O T U M A N 

Gloves Off 40 

A surgeon turns to writing to help dissect the medical profession. 

an interview with A T u L gawande, by elissa ELY 

The Case of the Canine Caper and Other Tales 44 

Pantmg pooches, hidden heartbeats, perilous peregrinations, and 
wiggly worms figure in one physician's collection of whimsical 
medical memories. 


Joint Ventures 50 

Harvard's Surgical Research Laboratory has closed its doors 
after nearly a century of advances that boldly transformed the 
way medicine operates. 


Harvard Medieval 

A L U M N 

U L L E T I N 

In This Issue 

is dropped by parachute to save a Native woman in the Canadian 
north. Harvey Cushing's chauffeur deh\'ers a therapeutic shake to 
the eminent neurosurgeon's dog. And a Navajo man in a wheelchair lectures 
teenagers about the perils of alcohol, only to die a few months later, lying 
drunk in the cold of an Arizona night. 

The stories in this issue came to us from alumni and faculty from several 
generations and across the country. Yet it should come as no surprise that 
some common themes emerge. Certainly one of them is the extraordinary 
history of innovation at HMS. Another is that even the Harvard luminaries 
who now appear to represent a kind of monolithic, marble tradition were 
engaged in all kinds of rebellion and conflict, which were essential to the 
vitality of the institution. 

What strikes me in reading these articles, howe\'er, is how poignantly they 
illustrate a phenomenon so pervasive and apparent that the emotional punch 
of the facts is lost in the piety of their expression: how often privilege, or the 
lack thereof, trumps medical science. Yet an engaging counter-theme emerges 
in these same pieces: suimming against the tide is far from a hopeless endca\'or. 
Individual physicians faced with seemingly intractable problems can embrace 
the challenges and, on occasion, prevail. 

As I ha\'e noted before in this space, the Bulletin is primarily the product of 
HMS alumni. Unlike the magazines coming from virtually any other medical 
school, we stick to a long tradition of publishing, as much as possible, in the 
voices of our graduates. That said, we depend on a small and stellar staff of 
editor-writers to sustain the quality of the magazine. Thanks to their efforts, 
the Bulletin has again won a gold medal (in a field of 76 graduate school maga- 
zines) from CASE, the Council for Advancement and Support of Education. 
Along with Editor Paula Byron and Associate Editor Beverly Ballaro, Susan 
Cassidy as assistant editor had contributed to this effort. Susan has now moved 
to another post at Harvard, and we take this occasion to thank her and wish 
her well. Janice OTeary, who succeeds her as assistant editor, arrives with this 
issue, and we welcome her. 



William Ira Bennett '68 


Paula Brewer Byron 


Beverly Ballaro. PhD 


Janice O'Lear)' 


Elissa Ely '8 


Judy.'Vnn Bigby '78 
Rafael Campo '92 

Elissa Ely '88 

.Atul Gawande '94 

Robert M. Goldwyn '56 

Perri Klass '86 

Victoria McE\oy '75 

James J. O'Connell '82 

Nancy E. Oriol '79 

Eleanor Shore '55 


Laura McFadden 

&M[ \[\A 


Eve J. Higginbotham '79, president 

Joseph K. Hurd, Jr. '64, president elect 1 

Steven A. Schroeder '64, president elect 2 

Paula -A. Johnson '85, vice president 

PhyUis I. Gardner '76, secretar)' 
Kathleen E. Toomey '79, treasurer 


Nancy C. Andrews '87 

Gerald S. Foster '51 
Donnella S. Green '99 
Linda S. Hotchkiss '78 
Katherine A. Keeley '94 
BarbaraJ. McNeil '66 
Laurence J. Ronan'87 
Mark L. Rosenberg "72 

Kenneth I. Shine '61 


Daniel D. Federman '53 


Nora N. Nercessian, PhD 


Joseph K. Hurd '64 

The Hanard Mcika\ .Alumni Builrtin is 

published qu.jrterly at 25 Shactuck Street. 

Boston. M.A 02115 ^' by the Harvard 

Medical .Alumni .-Association. 

Phone: (617) 384 8900 • Fa.\; (617) 384 8901 


Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, M.A 02115 

ISSN 0191 7757 • Printed in the U.S.A. 





A Timely Prescription 

I am responding to the forward look 
ing and thought provoking "Presi- 
dent's Report" written by Mitchell 
Rabkin '55 in the summer issue of the 
Bulletin. In that column. Dr. Rabkin 
advocated the creation of a nursing 
school at Harvard. I write to endorse 
his proposal in the strongest possible 
terms, but for somewhat different rea- 
sons than he set forth. 

Dr. Rabkin pointed out, quite appro 
priately, that the shortage of registered 
nurses is already a major threat to the 
quality of health care. In the future this 
shortage could impose a catastrophic 
limitation on our ability to dcli\'cr high- 
quality care. I do not believe, however, 
that this workforce issue should 
be the primary inspiration that leads 
Harvard to create a nursing school. 
Rather, Harvard should create a school of 
nursing because nursing has become an 
established and increasingly important 
academic discipline. 

Nursing research has now been rec 
ognized by the creation of the National 
Institute of Nursing Research, one of the 
27 institutes comprising the National 
Institutes of Health. Peer-reviewed 
funding is even more highly competitive 
in nursing research than in the other 
research areas of the NIH. Nursing 
scholarship in areas such as medical 
anthropology, ethics, end of life and 
palliative care, psychosocial nursing, 
and pain management constitutes some 
of the strongest work in the field. All 
these areas desperately need research of 
the quantity and quality one expects 
from Harvard. Simply put, Harvard 
should create a nursing school because 
nursing is a major area of scholarship to 
which Harvard contributes less than it 
could and should. 

A number of outstanding nurse' 
scholars do call the Harvard communi- 
ty home. They have achieved interna- 
tional impact despite being handi 
capped by having no nursing school of 
their own, no dean to advocate for their 

• • Nursing scholarship in areas such as medical 
anthropology, ethics, end-of-life and palliative care, 
psychosocial nursing, and pain management con- 
stitutes some of the strongest work in the field." 


area, and no internationally preeminent 
board of overseers to serve as their 
advocates and advisors. They con- 
tribute without the leverage for extra 
mural research resources that only an 
organized school can bring to a major 
academic discipline. The accomplish- 
ments of these nursing leaders are, 
therefore, all the more remarkable. 
Imagine w'hat impact they could have if 
they had Harvard's imprimatur. 

It is instructive to survey the status of 
nursing at the other universities whose 
schools of medicine rank in the top tier 
in the United States. Schools that rival 
Harvard Medical School — such as Johns 
Hopkins, the University of California at 

San Francisco, the University of Penn- 
sylvania, the University of Michigan, the 
University of Washington, Case West- 
ern Uni\'ersity, and yes, even Yale — all 
ha\'e outstanding schools of nursing as 
partners. All are producing leaders who 
are influencing health care, shaping 
public policy, and altering the direction 
of biomedical research in areas such as 
pain and palliative care, symptom man- 
agement, complementary and integra- 
tive medicine, patient safety, and psy- 
chosocial oncology. Harvard is being left 
behind — and that is why we should 
have a school of nursing. 






Conserving Compassion 

My memorial for Neil Ghiso '01, 
published in the Summer 2002 issue of 
the Bulletin, prompted an outpouring of 
support for Neil's fainily and friends, as 
well as for the newly created Neil 
Samuel Ghiso Foundation for Compas- 
sionate Medical Care. 

I had mentioned in the memorial that 
the foundation was created to foster 
compassionate care for chronically and 
terminally ill patients and their families 
through medical education and training. 
As a follow-up for your readers, I would 
like to report that two very talented third- 
year HMS students, Da\'id Hwang '05 and 
Richard Lin '05, were named the first 
Neil S. Ghiso Foundation fellows this 
year. The fellowship, which was created 
with support from numerous HMS 
alumni, provides an opportunity for 

medical students to work with terminal- 
ly ill patients in order to develop their 
own clinical skills in end- of- life care and 
to conduct research projects aimed at 
identifying key issues in delivering quali- 
ty care for the terminally ill. 

The fellowship allowed David Hwang 
to spend one month working full time 
for the Massachusetts Compassionate 
Care Coalition, a statewide coalition to 
improve end-of-life care in the common- 
wealth. David worked with Compas- 
sion Sabbath, a multi faith initiative to 
provide clergy with training, tools, and 
resources to address the spiritual needs 
of dying people. 

Richard Lin, for his fellowship, devel- 
oped a research project to identify the 
needs of residents in long-term care 
facilities and barriers to the delivery of 
good palliative care. Richard created a 
questionnaire -based interview study at 


• • Throughout his illness, Neil spoke about the critical 
importance of compassion in medical care. This 
concept was never more evident to those close to Neil 
than in his last months, 'when the quality of his life 
was determined far more by the kind care he received 
from his medical team than by the sophisticated 
medical technology that was made available to him." 


the Sherrill House skilled nursing facili- 
ty in Jamaica Plain, Massachusetts, to 
investigate the physical, emotional, psy- 
chological, and spiritual needs of resi- 
dents in receiving palliative care. 

Throughout his illness, Neil spoke 
about the critical importance of com- 
passion in medical care. This concept 
was never more evident to those close to 
Neil than in his last months, when the 
quality of his life was determined far 
more by the kind care he recei\'ed from 
his medical team than by the sophisti- 
cated medical technology that was 
made available to him. 

Neil's family, friends, and colleagues 
hope that the foundation will honor his 
memory by providing opportunities for 
future doctors to recognize the unique 
needs of the terminally and chronically 
ill and to understand the critical role of 
compassion in caring for all patients. 


North Star 

Although we were ne\'er intimates of our 
classmate Andy Embick 77 and did not 
maintain personal contact with him after 
lea\'ing HMS, we were always fascinated 
by his destination of Alaska and by his 
multifaceted, rugged medical experi- 
ences there, described in his alumni 
updates. Thus, we were greatly saddened 
to read of his passing in the Great White 
North, and our prayers are with his fam- 
ily. For us, and we're sure for many of our 
classmates, our enduring memories of 
Andy are of his rappelling down the 
walls of Building A — chased by campus 
police — and cross-country skiing down 
Avenue Louis Pasteur on a snowy New 
Year's Eve. 


The Bulletin welcomes letters to the editor. 
Please send letters by mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115); fax (617-384 S901): or 
email (bullet in(<'>hms.haiyard.cdu). Letters may 
be edited for length or clarity. 




What Would Scooby Do? 


"Crcmaster and Comman- 
der: The Inner Side of the 
Thigh," took theatergoers 
on a Mystery Machine tour of HMS — 
with Velma, Daphne, Fred, Shaggy, and, 
of course, Scooby along for the ride. The 
audience cheered on the cartoon- 
inspired characters through two action - 
packed hours of HMS-based satire that 
was definitel)' for adults only. 

Directed hy Stephanie Krejcarek and 
Christopher Russell, this year's show 
included unabashedly gratuitous (and 
thoroughly enjoyable) dance numbers, 
razor- sharp portrayals of some of the 
School's most famous faculty, and 
enough sexual irmuendo to make Larry 
Fl)Tit proud. Just as amusing was the 
hilarious, true-to-life commentary by 
Richard Schwartzstein '79 as parodied 
by Conor Kleweno in a convincing per- 
formance of the physiology course direc- 
tor and lung lo\'er. 

The tale unfolds as Dean Joseph Mar- 
tin summons to his office Nancy Oriol '79; 
Shiv Pillai; Dana Stearns; Jeannie Hess; 
Paul Farmer '90 (complete with an ador 
ing, youthful female entourage); and 

Cindy Trudy-Sam — that is, 
Cindy McDermott, Trudy 
Van Houten, and Sam 
Kennedy, who throughout the 
show are literally joined at the 
hip. The dean has received 
reports of scandalous behavior 
by his faculty and has called 
them together to get to the bot- 
tom of the matter. In the middle of 
the meeting, though, Martin mys- 
teriously disappears. 

In true HMS fashion, an ad hoc 
committee is formed, composed of 
students Fred (New Pathway); 
Daphne (Dental); Velma (HST); 
Shaggy (a Second Year Show writer); 
and the requisite knockout mouse 
SCOobY (a genetically engi- 
neered obese mouse). They set 
out to find the missing dean, to 
solve the mystery, and, along 
the way, to write a murder 
mystery script for the Sec 
ond Year Show. 

The adept students soon 
find the one they believe 
to be the culprit — antibody- 
obsessed Shiv Pillai — only to 

faculty send-ups to a swaggering 
striptease, second-year students 
offered a comic take on HMS. 

disco\'er that yet another faculty member 
has been kidnapped. Soon, nearly the 
entire faculty is gone, snatched by an 
unknown abductor, which sparks a 
chase to find the real villain. 

Along the way, SCOobY and the gang 
watch Nancy Oriol and Bev Woo — por- 
trayed by Jona Hattangadi and Emily 
Pinto-Wong — duke it out for student 
affection. They also see Jeannie Hess as 
played by Stephanie Krejcarek vamp 
across stage as a C/iicago-style diva, and 
they witness an unlikely striptease by 
Dean Malcolm Cox 70 as played by the 
talented Ryan Dunlop. Finally, the vil- 
lain — none other than physiology drill 
sergeant Richard Schwartzstein — is 
caught in a rousing finale and sentenced 
to a lifetime of teaching the "touchy- 
feely" Healer's Art class for his crimes. 
Highlights of the show included 
beautifully performed traditional 
Nepali dance routines, choreo- 
graphed by Ruma Rajbhandari; a 
running spoof on Paul Farmer 
endowed with a Messianic 
complex, which included a 
scene with Farmer — fittingly 
played by Ted Lord — dressed 
up as Jesus; and the musical 
number "Hit the Road, 
Plaque," a twist on the 
Ray Charles classic that 
will surely be seen in a 
toothpaste commercial in 
the near future. 

Proceeds from this year's 

show will benefit the 

Martha Eliot Health Center 

Mentorship Program, which 

matches medical students as 

mentors with Mission Hill 

middle-school students. ■ 

Tamyn Grizzctrd '06 is a fourth 
year medical student at HMS. 




WEB FEAT: Sanjiv Chopra says that online 
CME modules will help extend medical 
learning to developing nations. 

Cyber Case 


education credits can now log on to 
Harvard Medical School's CME web- 
site from their homes or offices. Clini- 
cians can pursue their credits during 
the gaps in their day, logging on and off 
at their convenience and saving their 
work from one session to the next. 

More important, clinicians from 
around the world can take ad\'antage of 
this service, says Sanjiv Chopra, facult)' 
dean for continuing education and HMS 
professor of medicine at Beth Israel 
Deaconess Medical Center. Chopra cites 
a statement that Harvard President 
Lawrence Summers made during a grand 
rounds last year: "In the era of technolo- 
gy, we have an unprecedented opportu- 
nity, perhaps even a moral obUgation, to 
share information and knowledge with 
colleagues around the world." 

The School has worked to fulfill that 
obligation, offering 225 li\e CME courses 
and 400 in-hospital conferences, including 
grand rounds. But although approximate- 
1)' 50,000 clinicians attend these sessions, 
only 2,000 come from outside the United 
States, with most of these from Canada. 

For clinicians from the wealthiest 
countries, the fee for online CME is 525 
per credit. The rest of the world gets a 
50 percent discount, and Chopra hopes — 
through endowment, perhaps — eventu- 
ally to offer clinicians in de\'eloping coun- 
tries much more substantial discounts. 

Online CME provides more scope for 
learning than traditional venues, Chopra 
says. Whereas a grand rounds is general- 
ly restricted to an hour, an online module 
can be as long as necessary and can 
include any number of relevant \isuals. 
"We can show the EKG of a typical car- 

From the Laboratory to the Patient 


seven teaching hospitals, and 
nearly a hundred researchers 
are banding together in an 
ambitious new institute with a common 
goal; to use stem cells to help the 150 mil- 
lion people nationally living with or dying 
from five types of organ and tissue failure. 

To achieve its aims, the new Harvard 
Stem Cell Institute will mount the largest, 
most comprehensive effort of its kind. It 
will tap resources across the University, 
break new scientific ground, pioneer 
new medical treatments, identify signifi- 
cant nongovernmental funding sources, 
and wrestle with ethical, religious, and 
political ramifications. 

Along the way, the institute will bring 
together isolated investigators who are 
already performing cutting-edge stem cell 
research, making Harvard one of the lead- 
ing centers for this type of work in the world. 

"The Harvard Stem Cell Institute is an 
important effort to help unlock one of the 

fundamental mysteries of life, and could 
lead to important new medical treatments," 
said Harvard President Lawrence Summers. 

Stem cells, with their ability to develop 
into specialized tissue cells, have excited 
researchers with their promise. By under- 
standing how they work, researchers hope 
they can learn to develop nerve, blood, 
bone, and other kinds of cells to be used 
to treat a wide spectrum of diseases. 

The institute will encourage stem cell 
research on several fronts. Research into 
adult stem cells is the most advanced. These 
cells create specific tissue types, such as 
blood, nerve, or muscle. Blood stem cells are 
already being used in treatments, particular- 
ly for leukemia and other blood cancers. 
Work on adult and embryonic stem cells in 
animals, as a way to understand their func- 
tion in humans, is also progressing rapidly. 

Some of the most promising — and con- 
troversial — stem cell work is with human 
embryonic stem cells. Embryonic stem cells 
ore unique because they can develop into 

any cell in the body. The Harvard Stem 
Cell Research Committee, established to 
review nonfederally funded research on 
human embryonic stem cells, will review 
research proposals before they go forward. 

In addition to the research being con- 
ducted by investigators at the Faculty 
of Arts and Sciences, Harvard Medical 
School, and Harvard's teaching hospi- 
tals, the institute will draw on resources 
across the University to examine the ethi- 
cal, political, religious, economic, and 
other ramifications of the research. 

"Given the potential we have here, 
to not take advantage of it would be a 
tragedy in a way," said institute Co-Direc- 
tor and Harvard Medical School Professor 
David Scadden, who also serves as direc- 
tor of Massachusetts General Hospital's 
Center for Regenerative Medicine and 
Technology. "We hope to create a cru- 
cible in which these interactions among 
researchers will happen." 

In its initial phase, the institute will be a 
"virtual" center, supporting research and 
drawing scientists together who work in 
laboratories that may be physically distant. 



diac lesion," Chopra says. "We can show 
the cardiac echo, a hemodynamic trac 
ing, and cardiac catheterization. We 
can let the natural history of the disease 
unfold, and we can show what we 
would be likely to see five years hence if 
the patient went untreated." 

Within three months after the first 
module became a\'ailable, and without 
any marketing, 129 clinicians from more 
than 20 countries had already taken 
ad\'antage of the service. 

"Our goal is to take the top 50 to 60 
diagnoses that primary care physicians 
deal with on a daily basis and dex'elop 
modules for those first," Chopra says. 
Once that goal is achieved, he plans to 
move into the specialties. 

Users log on to, then select "CME Online." 
Then they choose from a smorgasbord 


U.S. News c-Woild Report has named HMS fhe number one medical school in the 
research category for the 14th year in a row. The School also took top ranking 
for its pediatrics and women's health programs, second place for its internal medi- 
cine and drug/alcohol abuse programs, and third place for its AIDS programs. 
The schools that followed HMS among the top five overall were Washington 
University, Johns hlopkins University, and, tying for fourth place, Duke University 
and the University of Pennsylvania. ■ 
»'-jii'" ... ,. ' • 

of topics, such as "Clinical Challenges 
in Electrocardiography" or "St. John's 
Wort and Depression: What's the E\'i- 
dence?" Erom there, they can review a 
sample case, or dive right into a module. 

in the typical case, the users read the 
patient's history, analyze the results of a 
physical examination and laboratory 
tests, and then get a question with sever 
al possible an.swers. If they give an incor 
rect answer, they try again. If they gi\'e 
the right answer, they can still read the 
experts' advice about why the other 
responses are WTong. 

In the sample case, the users find out 
that the patient — a 42 year old woman 



with fever, flank pain, \'omiting, palpita- 
tions, and escalating feehngs of anxi 
ety — has hyperthyroidism. They then 
review the disorders other than Gra\'es' 
disease that can cause the condition. 
They view a goiter and are asked which 
physical exam findings pro\ided in the 
lesson would support the diagnosis. The 
rest of the questions are followed by 
more information about the case. 

Chopra is enthusiastic about the task. 
"I feel privileged," he says, "because I 
work with some of the most brilliant, 
ebullient, and dedicated faculty." ■ 

Da\'id Holzman is a frcckwcc writer for Eocus. 

Researchers will develop core laboratory 
facilities end needed technology to perform 
functions such as cell sorting, imaging of 
stem cells in their natural environments, and 
the transfer of nuclei between ceils. 

Within a few years, Scadden and 
the institute's other co-director, Douglas 
Melton, the Thomas Dudley Cabot Profes- 
sor in the Natural Sciences at Harvard, 
hope to add a central physical location for 
the institute, complete with laboratory facil- 
ities. Though some researchers would con- 
tinue to work in their own labs at different 
locations, the physical closeness of a cen- 
tral lob facility should allow informal meet- 
ings and foster an environment that will 
lead to new ideas and lines of inquiry. 

Although basic science is critical to the 
effort, Scadden said the institute's main 
goal is to develop scientific advancements 
into practical treatments for patients. 

Howard Heffron, a graduate of Har- 
vard Law School, donated $5 million 
toward the establishment of the new insti- 
tute because, he says, he wanted to help 
fill the void left by the federal government. 
Stem cell research has promise to help 

people like his daughter Nancy, who has 
diabetes, and his close friend, the late Law 
School Dean James Vorenberg, who hod 
Parkinson's disease. 

The new institute is focused on five dis- 
ease types for which stem cell therapy 
seems most promising. These diseases all 
result from some sort of organ or tissue foif 
ure: diabetes; neurodegenerative diseases; 
blood and immune diseases; cardiovascu- 
lar disease; and musculoskeletal diseases. 

Leonard Zon, an HMS professor of 
pediatrics at Children's Hospital and pres- 
ident of the International Society for Stem 
Cell Research, said other institutions such 
OS Stanford University have already orga- 
nized stem cell efforts, but few hove the 
resources already present at Harvard. 

"We have a tremendous intellectual 
community already existing, and when 
drawn together I think there will be 
nobody who can possibly touch us," Zon 
said. "I think the stimulation for the entire 
field will be tremendous." ■ 

Alvin Powdl is a writer with the Harvard 
University Gazette. 





Rescue Heroes 


l^nj I Medical Surgical Response 
1^^ I Team (IMSuRT) in Boston 
■■■■ did not expect their winter 
holiday to involve a \'oyage halfway 
around the world. But when a 6.8'mag- 
nitude earthquake struck Bam, Iran, on 
December 26, 2003, Susan Briggs, the 
supervising medical officer, and her team 
were deployed less than a day later. 

Briggs, associate director of the trau- 
ma service at Massachusetts General 
Hospital and HMS associate professor 
of surgery, heads the team of 140 trauma 
specialists, surgeons, anesthesiologists, 
nurses, respiratory therapists, biomed- 
ical engineers, and paramedics. Togeth 
er they make up the first rapidly 

deployable expert team equipped to 
establish a fully capable, freestanding 
field surgical facility anywhere in the 
world. Nearly 100 members of the team 
work at Harvard affiliates, and 58 of 
them made the journey to Bam. 

"When I heard they were considering 
sending us to Iran, I didn't think we 
would be allowed in," says Briggs. Her 
team was the first to enter the country in 

an official U.S. government capacity 
since the 1979 Islamic Revolution. 

"You couldn't set up in the center of 
to\\Ti," says Briggs. "Se\enty percent of it 
was destroyed." The earthquake claimed 
more than 26,000 lives and injured 
approximately 20,000 people. 

Because of Iranian cultural traditions, 
IMSuRT had to improvise its standard 
setup and create separate treatment facil- 
ities for men and women rather than the 
usual acute and non-acute designations. 
Iranian women could onl\' be treated by 
women, and all v\-omen were expected to 
have their heads covered in pubhc. 

"W'e had brought wool caps, but it 
got too hot to wear them during the 
day," Briggs says, "so we cut arm slings 
to use as hats." 

IMSuRT treated 727 patients, per- 
formed se\'en operations, and assisted in 
six h\'e births — r\\'o by Cesarean — in 
their 12-day stint in the field hospital. 
One of the babies, born prematurely at 
32 weeks, had to be hand-ventilated by 
respiratory therapists for ten hours until 
the child could be med- flighted to 
Tehran for further treatment. 

"We saw all kinds of injuries, including 
a lot of pulmonary problems because of all 
the dust," says Briggs, \\-hose humanitari- 
an medical rehef work took her to Turkey 
following its 1999 earthquake. 

Interpreters translated Farsi for 
IMSuRT members, but it was a combina- 
tion of the language barrier and the dev- 
astation the Iranian people had faced 
that was most difficult for Briggs. "Some 
of them lost 20 to 40 family members. 
The language barrier made medical care 
and emotional support difficult to give." 

Critical specialists, including Briggs, 
stayed in the field hospital around the 
clock. "We slept on the floor of the oper- 
ating room and rotated people between 
tents in 12-hour shifts," she says. 

Before they left on Januar}' 7 IMSuRT 
donated their entire hospital to the Islamic 
Red Crescent Societ)'. "The most reward- 
ing part," Briggs says, "was to see that pol- 
itics was put aside to let us fulfill a need." ■ 

Leah Gow]c\ i.s an editorial assistant at Focus. 




Striking a Match 


revealed to 175 HMS fourth year stu- 
dents where they will be spending their 
residencies. Ninety-four percent of this 
year's graduating class chose to pursue 
chnical programs, with internal medi 
cine as the most popular specialty, at 23 
percent. Pediatrics was the second most 
popular specialty, at 12 percent, followed 
by radiology at 8 percent and ophthal 
mology and emergency medicine, both at 
7 percent. Just over half of the fourth 
years will remain in Massachusetts, and 
94 percent of these will be at HMS-affil 
iated hospitals. California and New York 
drew a combined third of the class, with 
21 and 12 percent respectively. 


Jordan Brand 

New York Presbyterian Hospital 


Tomas Cvrk 

Massachusetts General Hospital 

Boris Spelctor 

Massachusetts General Hospital 

Michael Chi^ei Su 

Brigham and Women's Hospital 


April Armstrong 

Massachusetts General Hospital 

Heather Brandling-Bennett 

MassQchusetis Geneial Hospita 

Elizabeth Buzney 

Massachusetts General Hospital 

Vinh Chung 

Emor/ University, Atlanta 

Jean Lee 

Massachusetts General Hospital 

Moyro Lorenzo 

University of Massachusetts 
Medical School, Worcester 

Laura Pincus 

University of California- 
San Francisco 

Michael W. C. Su 

University of California-Davis 

Medicol Center 

Ryan Turner 

Massachusetts General Hospital 


Ryan Chuang 

Jnive'sity Hospital, Cincinnati 

J. Drew Colfax 

Vonderbilt University Medical 

James De La Torre 

University or southern California 

Heidi Harbison 

Brigham and Women's Hospital 

Renee Hsia 

Stanford University Programs 

Jerrilyn Jones 

Boston UniversiK' Medical Center 

Alexander Lam 

Boston University Medical Center 

Marisela Marrero 

Brigham and Women's Hospital 

Suzanne Miller 

Stanford University Programs 

Erick Miranda 

University of Southern California 
Tami Tiamfook 

Brigham and Women's Hospital 


Aya Kuribayashi 

Swedish Medical Center, Seattle 

Anje Van Berckelaer 

Harbor-UCLA Medical Center, 
Torrance, CA 


Damon Clark 

Eastern Virginia Medical School 

Scott Damrauer 

Massachusetts General Hospital 

Jonathan Fox 

Massachusetts General Hospital 

Joaquim Havens 

Brighom and Women s Hospital 

Ugwuji Maduek>ve 

Massachusetts General Hospital 

Travis McGlothin 

University of New Mexico, 

Joan Ryoo 

Brigham and Women's Hospital 


Ehrin Armstrong 

Massachusetts General Hospital 

Jeffrey Bander 

New York Presbyterian Hospital 


Amy Barczak 

Massachusetts General Hospital 

Mallar Bhattachoryo 

Johns Hopkins Hospito 

Sonoli Bose 

Mt S-no, Hospital New York, NY 

Rebecca Breslovy^ 

Brigham and Women's Hospital 

Supinda Bunyavanich 

Massachusetts General Hospital 

Jeffrey Chung 

Massachusetts General Hospital 

Lori Coburn 

Vonderbilt University Medical 

Adam Cohen 

Good Samaritan Regional 
Medical Center, Phoenix 

Elizabeth Comen 

Mt. Sinoi Hospital, New York, NY 

Brian Graham 

University of Colorado School 
of Medicine, Denver 

Anna Greka 

Massachusetts General Hospital 

Choo-Wei H>vang 

Bngham and Womens Hospital 

James ip 

Brigham and Women's Hospital 

Helina Kassahun 

Johns Hopkins Hospital 

Rahul Kohli 

Hospital of the University of 
Pennsylvania, Philadelphia 

Sophia Koo 

Brigham and Women's Hospital 

Wei Lin 

Massachusetts General Hospital 

Moriso Mogana 

University of California-San 
Diego Medical Center 

Rajeev Malhotra 

Massachusetts General Hospital 

Alden McDonald 

Massachusetts General Hospital 


Jl \ ) I i iT; Pi 


Luis Munoz 

Slantofd University Programs 

Taylor Ortiz 

McGaw Medical Center, North- 
western University Programs 

Atara Schultz 

Mt. Sinai Hospital, New York, NY 

David Ting 

Massachusetts General Hospital 

Brian Turner 

Brighom and Women's Hospital 

Sarah Valkenburgli 

Brown University 

Ariel Weissmann 

Boston University Medical Center 

Eric Williams 

University of California- 
Son Francisco 

Markella Zanni 

Bngham and Women's Hospital 


Nazleen Bharmal 

Brighom and Women's Hospital 

Brian Chan 

Massachusetts General Hospital 

Stephanie Cohen 

University of Colifornio- 
San Francisco 

Andrew Ellner 

Brighom and Women's Hospital 

Marshall Fordyce 

NYU School of Miedicine 

Julie Levison 

Brighom and Women's Hospital 

Mehret Mandefro 

Einstein/Montefiore Medical Center 

Mary Thorndike 

Brighom and Women's Hospital 


Douglas Krakov^er 

Harvard/Massachusetts General 


Rachel Goldmann 

University of Pennsylvania, 

William Taylor Kimberly 

Hansard/ Massachusetts Generol 
& Brighom and Women's Hospitals 

Eric Rosenthal 

Harvard/Massachusetts General 
& Brighom and Women's Hospitals 

Michael Ty 

Harvard/Massachusetts General 
& Brighom and Women's Hospitals 


Catherine Chu 

Children s Hospital, Boston 

Suzanne Goh 

University of California- 
San Francisco 


Joseph Hsieh 

University of Chicago 

Rollin Hu 

Harvard/Massachusetts General 


Christina Dancz 

University of Southern California 

Liyun Li 

University of California- 
San Francisco 

Shruthi Mahalingaiah 

Brighom and Women's Hospital 

Ngoc Phan 

University of California- 
Son Francisco 

Amino Porter 

Georgetown University Hospital 


Isabel Bolderas 

Tufts/Nevv England Eye Center 

Teresa Choe 

Baylor College of Medicine, 

Julie Chen 

University of California- 
San Francisco 

Susan Hoki 

University of Southern California 

Aaron Kuzin 

Universit/ of Southern California 

Dalia Nagei 

Mt. Sinai School of Medicine 

Yvonne Ou 

Universif/ of Californio-Los Angeles 

Harsha Reddy 

Univ-ersir,' or Southern California 

Lucy Shen 

University of Californio-Los Angeles 

Gregory Sulkov^ski 

University of Illinois, Chicago 

Sara Tullis 

University of Miomi/Boscom 
Palmer Eye Institute 

Deborah Yeh 

University of Michigan, Ann Arbor 


Killion MocCorthy 

Mossochusetts General Hospital 

Steven Smullin 

Massachusetts General Hospital 

Derek Steinbacher 

Mossochusetts General Hospital 


Julius Bishop 

Harvard/Massachusetts General 

Sumeet Garg 

Ba"--;.-.'. .' -:soital, St. Louis 

Coleen Sobotini 

Harvard/Massachusetts General 


Biono Litrovnik 

NYU Sc-oc' of 'v'ed^cine 

Stephanie Misono 

Universft/ or Washington, Seattle 

Andrews Scott 

Harvard Programs 


Samuel Katz 

Brighom and Women's Hospital 

Vikrom Kumar 

Brighom ond Women's Hospital 


Kathryn Brinner 

Mossochusetts General Hospital 

Janet Chou 

Childrens HosDitol Boston 

Katharine Creskoff 

Children's Hospital, Boston 

Andrew Dauber 

Children's Hospital, Boston 

Michelle Day 

Massachusetts General Hospital 




Kevin Friedman 

University ot Colorado School 
of Medicine, Denver 

Noelle Johnstone 

Stanford Ur versiN Programs 

Rebecca Locke 

New York Presbyterian Hospital 

Erica McAuliffe 

Children's Memorial Hospitol, 

Lauren Palmer 

University of California-San 
Diego Medical Center 

Sallie Permar 

Children's Hospital, Boston 

Lynn Ramirez 

University of California- 
San Francisco 

Paul Rosenau 

University of Vermont/Fletcher 

Allen Hospital, Burlington 

Kristi Stanton 

Children's Hospital, Boston 

Jeremy Tucker 

Baylor College of Medicine, 

Sabrina Vineberg 

Johns Hopkins Hospital 

Scott Weiss 

Children's Hospital, Boston 

Katharine Zuckerman 

Mossacnusens General i-iospiral 


Jamal Harris 

Einstein/AAontefiore AAedical Center 

Bergen Nelson 

University of California- 
San Francisco 


lleono Howard 

University of Washington 
Affiliated Hospitals, Seattle 

Kelly Scott 

McGaw Medical Center/ 
Northwestern University Programs 


Marcus Ko 

Baylor College of Medicine, 

Cristina Vieira 

NYU School of Medicine 


Edmund Griffin 

New York Presbyterian Hospital 

Alisa Land 

UCLA Neuropsychology Institute 

Elizabeth LaRusso 

Harvard Longwood Psychiatry 

Kristin Leight 

New Yor< rresDyierian Hospital 

Alan Mayfield 

University of Californio- 
San Diego 

Jonathan Merson 

NYU School of Medicine 

David Quinn 

Massachusetts General 
Hospital/McLean Hospital 

Carolyn Rodriguez 

New York Presbyte'ian Hospital 

Gisela Sandoval 

University of Chicago Hospital 


R. Scott Bermudez 

University of California- 
San Francisco 

Linda Chan 

University of California- 
Son Francisco 

Ronald Chen 

Bnghorn and Women's Hospitol 

Victoria Croog 

Memorial Sloon-Kettering 
Cancer Center 

Ruben Fragoso 

Thomas Jefferson University, 

Christopher Myers 

University of Texos/MD Anderson 
Cancer Center, Houston 

Paul Nguyen 

Brighom and Women's Hospital 

What's New at HMS: 

The Fourth Annual Mollis L. Albright '31 Symposium 

The Positive Potential of Stem Cells 

George Q. Daley '91, PhD 

Executive Committee, Harvard Stem Cell institute 

with Dean Joseph B. Martin, MD, PhD 

and Dean Daniel D. Federman '53, Moderator 

Wednesday, October 1 3, 2004, 4:00 to 6:00 p.m. 

New Research Building, 77 Avenue Louis Pasteur 

For more information contact Tenley Albright '61 at or 617-247-8202 

Andrew Wang 

Brigham and Women's Hospital 


Lea Alhilali 

University of Texas Southwestern 

Medical School, Dallas 

David Boyajian 

New York Presbyterian Hospital 

Daniel Garza 

Horbor-UCIA Medical Center 

Antonio Gutierrez 

UCLA Medical Center 

Brook Hill 

Jackson Memorial Hospital, Miami 

Ravi Kamath 

Ay\assachusetts General Hospital 

Jessica Leung 

University of Washington 
Affilioted Hospitals, Seattle 

Weichung Liu 

UCLA Medicol Center 

Kalpona Mani 

Beth Israel Deaconess Medical 

Amin Matin 

UCLA Medicoi Center 

Javier Nazario Larrieu 

Baylor College of Medicine, 

Michael Powell 

Betti Israel Deaconess Medical 

Ori Preis 

Massachusetts General Hospital 

Grace Tye 

Stanford University Programs 

Jeff Velez 

Beth Israel Deaconess Medical 


Sandeep Datta 

Postdoctoral Fellow, Center for 
Neurobiology and Behavior, 
Columbia University 

Elissa Gaies 

Non-clinical pursuit 

Alvan ikoku 

Doctoral candidate in English 
and Comparative Literature, 
Columbia University 

Alice Jacobs 

Chairman and CEO, Intelligent- 
MD, Cambridge, AAA 

Wynn Kao 

Postdoctoral reseorch 

Ken>vay Louie 

Postdoctoral research 

Alvin May 

Non-clinical pursuit 

Christopher McGuire 

Eisenhower Army Medical 
Center, Fort Gordon, GA 

Kelvin Neu 

Associate, Baker Brothers Advi- 
sors, and co-founder, Southeast 
Asian Leadership Initiative, New 

York, NY 

Kristina Steenson 

Public health outreach, Siloam 
Family Health Center, Nashville 





met intensi\'ely for two days 
to discuss its mode of operat- 
ing, strategies to enhance its 
effectiveness, and plans for its future. 
Although this brief description may sug- 
gest a strategic planning process, the 
meeting may be more aptly character- 
ized as a prelude to a more ambitious 
endeavor to map the Council's activities 
for the next three to fi\'e years. 

Given that the Council's last retreat 
was held in 1985, several meaty issues 
required attention before a "blue sky" 
discussion of mission, vision, and values 

The median amount for those who 
assume debt has increased from 522,000 
for public schools and S27,000 for pri 
vate schools in 1984 to $100,000 and 
$135,000 respectively, in 2003. Given the 
expenses, it is no surprise to learn that 
more than 60 percent of medical stu- 
dents emanate from families in the top 
quintile of family income. Even so, more 
than 80 percent of all medical graduates 
leave school with some debt. 

So how is HMS faring with this issue? 
Although HMS debt levels are signifi- 
cantly lower than the national a\'erage, 
the mean medical school debt at gradua- 

the generosity of many alumni — will 
soon reach its S35 million goal. 

Council members are concerned, how- 
ever, that this funding may not be enough, 
since tuition will increase yet another 
7 percent this coming year and will likely 
continue to rise. For now, the Council 
wishes to emphasize the importance of 
this issue and to encourage alumni to 
contribute generously to the Scholarship 
Fund. For the next two years, this initia- 
tive will dominate the Council's agenda as 
we seek to develop additional strategies 
to make HMS accessible to all students, 
regardless of socioeconomic background. 

The mean medical school debt at graduation for the 
Class of 2003 was a remarkable $71,719. In fact, 
70 percent of the class carried medical school debt. 

could take place. The meeting offered an 
opportunity for Council members to 
join our opinions with those voiced in 
the recent HMS alumni survey to create 
an action-oriented blueprint that will 
shape the group's agenda for at least the 
next two years. Although space con- 
straints preclude me from providing a 
full accounting of the ten hours of our 
discourse, I would like to share one 
topic that will dominate the Council's 
work for the next several meetings — 
student indebtedness. 

Student indebtedness is not only a 
concern to HMS students but also to the 
entire community of medical educators 
and, by extension, the medical profes- 
sion. Recently the American Association 
of Medical Colleges issued a report on 
the current state of student indebted- 
ness. Some of the findings were startling. 
Since 1984, for example, increases in 
median tuition and fees have risen 50 
percent for private medical schools and 
133 percent for public medical schools, 
based on constant dollars. 

tion for the Class of 2003 was still a 
remarkable $71,719. In fact, 70 percent of 
the graduates of the class carried medical 
school debt, which does not take into 
account the other expenses a student 
may incur, such as credit card debt, auto- 
mobile loans, and even home mortgages. 
The burden of debt may make a fourth- 
year student think twice before consid- 
ering a career as a full-time researcher or 
a primary care physician. 

What is HMS doing about this issue? 
The School, in collaboration with the 
President's Office of Harvard University, 
has initiated an alumni loan repayment 
demonstration program. Qualified par 
ticipants working in lower-paying posi- 
tions will receive grants to cover their 
loan repayments. 

In addition, Daniel Federman '53, the 
senior dean for alumni relations and 
chnical teaching, and Robert Glaser '43B 
have been spearheading the Scholarship 
Campaign, which — thanks to the tar 
geted giving of those classes celebrating 
their 25th, 40th, and 50th reunions and 

Student indebtedness affects us all 
as we consider the possibility of losing 
highly qualified candidates because of 
the expense of medical education. 
HMS cultivates the leaders of the next 
generation; no medical student should 
be left behind. Although the need- 
based scholarship budget for HMS was 
second only to Stanford's in 2002, we 
should seek to go beyond our competi- 
tor in this category. Harvard leads the 
list of medical schools with regard 
to research and education. Harvard 
should also lead the way in its ability to 
provide more scholarships. 

This past winter Harvard President 
Lawrence Summers announced his plan 
to eliminate the requirement that 
parents contribute to Harvard under- 
graduate costs for families with an 
annual income below $40,000. Can we 
do the same for HMS students? ■ 

Eve J. Higginbotham 79 is chair of the Depart- 
ment of Ophthalmolog}' at the University of 
\lar\hnd School of Medicine. 







,". MiJnighr t ;_ 
''' Disease -rr. 
i ■ ^ 

Quirky Kids 

Understanding and Helping Your Child Who 
Docsnt Fit In. by Perri Klass '86 and 
Eileen Costello (Ballantinc Books, 2003) 

This book offers guidance on how to spot 
childhood "quirks" that might signal dis- 
orders. Practical ad\ice aids parents in 
nax-igating school systems, intervention 
programs, specialists, medications, social 
situations, and familial issues. The 
authors, both pediatricians and mothers, 
mine their extensive experience and 
compassion to illuminate the challenges 
of raising unusud kids and to embrace the 
differences that set these children apart. 

The Midnight Disease 

The Dn\c to W rite. W 'nter's Block, and the 
Creative Brain, by Alice Flaherty '94 
(Houghton Mifflin. 2004) 

The author, a neurologist, examines the 
roles the temporal lobes and limbic sys 
tem play in the desire to write. Her in\-es 
tigations into hypergraphia, writer's 
block, and procrastination are enriched 
by personal, professional, and literary 
anecdotes that add humor, poignancy, 
and insight to the carefully explained 


Clinical Guide to Glaucoma Management 

by Eve J. Higgmbotham "79 and Da\id A. 
Lee (ButtcrM'orth Heincmann, 2004) 

nearly 2.5 milhon Americans over the age 
of 40. The editors, both ophthalmolo- 
gists, focus on the epidemiology of the 
disease, the evaluation of individual 
patients, pharmacological and surgical 
treatments, and the business of risk man 
agemcnt. The 39 short chapters, which 
are illustrated with diagrams and color 
photographs, were created with the real 
ities of clinicians' busy schedules in mind. 

Them and Us 

Cult Jhmkmg and the Terrorist Threat, 
by Arthur J. Deikman '55 (Bay Tree 
Publishing, 2003) 

Deikman's treatise offers insight into the 
mind of the terrorist as well as into nor- 
mal inclinations to devalue outsiders 
with "good versus exil" dichotomies. The 
author, a p.sychiatrist, identifies four 
basic cult behaviors, illustrates how they 
operate, and offers suggestions to counter 
terrorism. He concludes powerfully: 
"There is no Them. There is only Us." 

Writing a History & Physical 

by Jeffrey L. Greenwald '94 (Hanky & 
Bclfus, 2003) 

Fifty-four experts contributed to this 
\olume on glaucoma, a affecting 

This straightforward, articulate book 
takes the physician step by step through 
both the content and purpose of each 
aspect of a history and physical. Helpful 
examples demonstrate both best meth- 
ods and pitfalls, with an emphasis on 
recording facts, not analyses or impres- 
sions. The book includes an abridged 
guide for at-a-glance reference. Practi 

cal even in size, Greenwald's book will 
fit in a lab coat pocket. 

Ornithine Transcarbamylase 

Basic Science and Clinical Considerations, by 
Philip J. Snodgrass '53 (K/uwer Academic 
Publishers, 2004) 

This text represents the author's 40 
years of research on ornithine transcar- 
bamylase (OTC) — one of five enzymes 
in the urea cycle, the first metabolic 
cycle to be identffied. Snodgrass, a gas- 
troenterologist and hepatologist, begins 
\\ ith the first documented cases of OTC 
deficiency in 1962 and examines the 
current knowledge on the genetics, 
pathology, clinical findings, and treat- 
ment of the deficiency. 

The Breakout Principle 

How to Activate the Isatural Trigger that 
Maximizes Creativity, Athletic Performance, 
Productivity, and Personal Well Being, 
by Herbert Benson '61 and William 
Proctor (Scribner, 2003) 

The authors provide practical techniques 
for personal transformation. They 
explain the physiological changes — par- 
ticularly the role of stress hormones, 
nitric oxide output, and brain activity — 
that occur when people experience 
"breakout" moments or peak perfor 
mances, and they offer advice on how to 
reach those moments regularly. The 
underlying principle, they WTite, is that 
letting go of problems helps solve 
those problems. 




New Clues — and Hopes — in the Fight Against Cystic Fibrosis 


on Mars has focused on the 
ancient lakebeds and river- 
beds that crisscross the Red 
Planet, and for good reason. Water is 
the medium of hfe. Cells are awash in it 
both inside and out. They also secrete 
fluids such as saliva, tears, sweat, 
mucus, and digestive juices through 
their many membrane channels. Usual- 
ly these secretions are aqueous and slip- 
pery, but in people v\ith cystic fibrosis, 
a genetic defect in one of the membrane 
channels upsets the water and chemical 
composition of the secretions, making 
them pathologically \iscous and sticky. 
It now appears that the cystic fibro- 
sis mutant gene may cause disease by 
altering the balance of another set of 
primordial molecules, the fatty acids. 
The discovery, reported by Steven 
Freedman 73 and colleagues in the Feb- 
ruary 5 issue of the New England journal 
of Medicine, could lead to a new under- 
standing, and possible treatments, not 
just of cystic fibrosis, but also of a host 
of related diseases such as pancreatitis, 
chronic sinusitis, and male infertihty. 

Too Hot to Handle 

For years, blame for the symptoms of 
cystic fibrosis was pinned on the vis- 
cous secretions, which clog up and 
produce life-threatening infections of 
the lungs. Over the past decade, more 
evidence suggests that the severity of 
these infections is the result of anoth^ 
er culprit, an overenthusiastic inflam- 
matory response. 

"It is not the bacteria so much as it 
is the host's exuberant response to the 
bugs that are just stuck there in the 
tenacious secretions," says Freedman, 
HMS associate professor of medicine 
at Beth Israel Deaconess Medical Cen- 
ter. "Your body is just attacking them, 
almost out of control, and the lung tis- 
sue is being destroyed as a kind of 
innocent bystander." 

But it was unclear how a mutation 
in a single channel protein, the cystic 
fibrosis transmembrane conductance 
regulator (CFTR), could produce two 
such divergent responses — viscous 
secretions and an overly reactive 
immune system. In 1999, Freedman 
and his colleagues showed that trans 
genie mice carrying two copies of the 
mutant CFTR gene produced an 
abnormal ratio of fatty acids. These 
long-chain molecules serve as building 
blocks for the cell membrane, and 
some are also precursors to important 
inflammatory proteins. Compared to 
wild-type mice, the mutants exhibited 
an excess of the pro-inflammatory 
fatty acid — arachidonic acid — and too 

little of the anti-inflammatory sub- 
strate — docosahexaenoic acid (DHA). 
Intriguingly, transgenic mice carr)'ing 
only one copy of the gene exhibited 
a ratio intermediate between the 
homozygotes and wild types. 

In a compelling breakthrough, 
Freedman and his colleagues discov- 
ered they could correct the fatty- acid 
imbalance and re\'erse disease by giv- 
ing the mice huge doses of DHA. 
Inspired by the findings, Freedman — 
along with Juan Alvarez, HMS associ- 
ate professor of obstetrics, g)Tiecology, 
and reproductive biology at Beth Israel 
Deaconess Medical Center; Michael 
Laposata, HMS professor of pathology 
at Massachusetts General Hospital; 

THE SKY'S THE LIMIT: Researchers are hopeful that new discoveries about the role of 
a fatty-acid imbalance may lead to effective therapies for people like five-year-old 
Joey, who v/as diagnosed with cystic fibrosis as an infant. 



The discovery could lead to possible treatments, not just of cystic fibrosis, 
but also of a host of related diseases, such as pancreatitis and male infertility. 

and colleagues — analyzed samples of 
C FT R- expressing cells from the plasma 
and nasal and rectal passages of 38 
patients with cystic fibrosis. 

The researchers found that the 
patients produced twice as much 
arachidonic acid, \\hich belongs to the 
omega-6 family of fatty acids, and one 
half as much DHA, a member of the 
omega 3 family, as those unaffected by 
the disease. People carrying only one 
copy of the mutant cystic fibrosis gene, 
who typically show no signs of disease, 
fell somewhere in the middle, suggest- 
ing that the mutant CFTR directly 
affects the fatty- acid ratio. 

Significantly, the researchers did not 
find a similar dramatic fatty-acid imbal- 
ance in people suffering from other 
forms of inflammation such as inflam- 

matory bowel disease, colitis, and cer- 
tain forms of asthma. "So inflammation 
alone," says Freedman, "does not lead 
to the fatty-acid abnormalities to the 
degree we see in cystic fibrosis." 

Therapeutic Approaches 

It is not clear how a defect in an ion 
channel protein causes the fatty- acid 
imbalance. The channel pumps ions out 
of the cell, particularly chloride, yet 
CFTR is thought to participate in many 
other aspects of cell function. "That is 
W'hat has made it, in part, so problemat 
ic to come up with a treatment for 
cystic fibrosis," says Freedman. The 
researchers have not yet tried to correct 
the fatty- acid imbalance in patients as 
they did in mice. 

"One problem is that the dose of DFLA 
we ga\'e the mice is \'ery high," Freeman 
adds. "If we extrapolate to humans, it 
would be six to seven grams of pure DHA. 
That is 30 or more over-the-counter cap- 
sules, and those are not that pure." 

In cystic fibrosis, the combination of 
\'iscous secretions and overexuberant 
inflammatory response wreaks havoc 
on the enzyme-producing pancreas and 
bile-producing liver. The approximately 
30,000 Americans affected by the dis- 
ease have a hard enough time digesting 
e\'en modest amounts of nutrients and 
must often take massive doses of 
enzymes. "They could never absorb that 
amount of DHA no matter how many 
pancreatic enzyme pills you gave them," 
says Freedman. He is talking with phar- 
maceutical companies about the possi- 
bility of developing a more concentrated 
and absorbable form. 

Cystic fibrosis patients and their 
families would gain most from such a 
formulation. Although the average life 
span of people with cystic fibrosis has 
doubled in the past few decades thanks 
to a combination of diet and physical 
therapy, it stiU is only 31 years — less 
than half the national average. 

Other patients might benefit as well. 
Freedman and his colleagues have found 
that 50 percent of people with pancre- 
atitis carry mutant versions of the 
CFTR protein. The mutant gene has 
also been found in 40 percent of people 
with chronic sinusitis and 30 percent 
v\'ith unexplained male infertility. 

Freedman, however, cautions all 
patients about rushing to self- medicate 
with o\'er the-counter omega-3 formula- 
tions. "I would be especially careful about 
supplementing in the cystic fibrosis popu- 
lation," he says. "It is ob\iously a devastat- 
ing disease. But we need to learn more 
about the role of DHA here. In particular, 
could there be side effects of high doses?" ■ 

Misia Landau is the senior science writer 
for Focus. 



by Gordon Worley 



A neurologist turns to 
lydrology, agronomy, 
and veterinary medicine 
to tackle the world's 
most preventable cause 
of mental retardation 


G. Robert DcLong '61 would toss 
sticks into creeks to gauge the speed 
of the water. Little could he have 
known how useful his childhood game would 
pro\e decades later, when he set out to eradicate a 
disease that for centuries had been devastating 
children in a remote corner of China. ■ DeLong 
traces his fascination with iodine deficiency disor- 
ders (IDD) to nearly 25 years ago, when his mentor, 
John Stanbury 39, suggested that he join a medical 
trip to Ecuador. "I thought the reports would turn 
out to be exaggerated," DeLong recalls. "But in a 
single month in an Andean mountain village I saw 
120 cases of a disease that, until then, I'd only read 
about in textbooks. These were people in whom 
prenatal iodine deficiency — and the resulting fetal 
hypothyroidism — had caused cretinism, character- 
ized by bhghted physical and mental development, 
spastic -rigidity, and deaf-mutism. The disease just 
debilitated the entire community." ■ DeLong 
remembers in particular one young woman whose 
hmbs were so twisted that she had to use her 
elbows to drag her body across the floor of her 
p~ - family hut, with all the painful laboriousness _ 



of a beached mermaid. Her family mem- 
bers would often prop her up outside, 
then carry her in when it began to rain. 

When this same young woman became 
pregnant, she might ha\'e gi\'en birth to a 
baby as impaired by iodine deficiency as 
she had been. But as part of the local IDD 
control project, she received an intramus- 
cular injection of iodine- in-oil during the 
second trimester of her pregnancy. The 
daughter she delivered is now a college 
graduate who speaks three languages. 

In the decades since his first encoun- 
ters with IDD, DeLong, a professor of 
pediatric neurology at Duke University, 
has witnessed many other instances of 
the transformative power of ex'en tiny 
doses of iodine in pre\'enting the disor- 
der. So when he encountered unusually 
high rates of the disease in Xinjiang, 


SOMETHING IN THE WATER: Clockwise from bottom left: on irrigation canal in Xinjiang 
>vhere a potassium iodate dripping helped replenish the health of several villages; 
a Uighur mother and child; Nancy and Robert DeLong comforting a young patient 

a province in northwestern China, he 
became determined to find a solution. 

The Salt of the Earth 

Symptoms of iodine deficiency have 
plagued humankind for millennia. A 
second- century frieze of Buddha and his 
disciples, for example, shows a figure 
with goiter. Drawings from the thir- 
teenth century depict people with goiter 
and cretinism, and Renaissance painters 
from Diirer to Rubens captured on can- 
vas many subjects with goitrous necks. 

Today, iodine deficiency still condemns 
many thousands of children to cretinism. 

tens of milhons to \'ar)'ing degrees of men- 
tal retardation, and hundreds of millions 
to milder degrees of mental and ph\'sical 
impairments. An estimated 1.6 billion 
people are at risk for IDD, no\\' recognized 
as the most common pre\'entable cause of 
mental retardation worldwide. 

Nearly one-third of the globe's inhabi- 
tants li\'e in areas of natural iodine defi- 
ciency. The regions most affected are 
mountainous ones, where glaciation, 
snow, and rainfall leach the mineral from 
the soil; flood plains such as that of the 
Ganges; and inland continental expanses 
far from the world's oceans, which are the 
primary sources of iodine. 




Countries around the world have 
responded to the problem, adding iodine 
to tea in Tibet, bread in Australia, and 
fish paste in Thailand. Yet fortifying ordi 
nary table salt with iodine, the most 
common method, is also considered the 
best. IDD was endemic in the Appalachi- 
an, Great Lakes, and mountainous west- 
ern regions of the United States, for 
example, until the 1920s, \\hen iodized 
salt consumption became widespread. 

Iodized salt does not offer a solution for 
people h\ing in many remote areas of the 
world, though. Some communities find it 
too expensi\e or difficult to obtain: others 
reject it as less fla\orful than locally a\ail- 
able salt. Efforts to provide oral or inject- 
ed iodine in oil to people living In areas 
with endemic IDD often fail because of 
issues of cost, distribution, or sustainabtl 

it)'. Cultural traditions and superstitions 
may create obstacles as v\'ell. 

Testing the Waters 

The problem of iodine deficiency is hard 
ly new to Xinjiang; while traveling 
through the region during the thirteenth 
century, Marco Polo recorded observa- 
tions of people with diminished intelli- 
gence, deafness, spasticity, and enlarged 
throats. Throughout the intervening 
centuries, the tragic consequences of 
iodine deficiency have continued to 
plague Xinjiang, whose water and soil 
contain some of the planet's lowest levels 
of naturally occurring iodine. 

A constellation of factors had con- 
tributed to the failure of efforts to pro\ide 
the people of Xinjiang with iodine. Some 
of the barriers were cultural. Forty per- 
cent of the region's inhabitants are 
Uighurs, a Turkic people who comprise 
the largest of China's minority groups. 
The Uighurs — most of whom li\'e in vil- 
lages dotting the perimeter of the Takli- 
makan Desert — find iodized salt not only 
less affordable, but also less savory than 
the rock salt so abundant in the desert. 

"The Uighurs ha\'e a tradition of pick- 
ing rock salt off the desert floor, dissolv- 
ing it in big clay pots, and then using the 
brine for cooking," DeLong says. "The 
desert salt has a 'brighter' flavor — likely 
from its magnesium content — but unfor- 
tunately it contains little iodine." 

Exacerbating the problem was the 
centuries-long contentious relationship 
between the Uighurs and the majority 
Han, who dominate the country's cen- 
tral government. And so the Chinese 
authorities' attempt to offer iodine piEs 
failed, among other reasons, because the 
Uighur women suspected officials of 
trying to slip them contraceptives. 

Efforts to introduce iodine intramus- 
cularly had fallen short as well. Injections 
such as those used in Ecuador required 
medical experrise and supphes not wide- 
ly a\'ailable in Xinjiang. And local public 

health authorities w^ere skittish about 
injections for another reason; in 1988, the 
area had suffered a hepatitis epidemic 
that had left 500 dead, and they wanted 
to a\oid the risks of shared needles. 

When DeLong first \isited Xinjiang in 
1989, he found one in ten children suffer- 
ing from severe IDD and one in three 
exhibiting symptoms of iodine deficien- 
cy. "We were examining literally hun- 
dreds of children," he says. "Some showed 
extreme mental retardation and could 
not walk, stand, or even sit. Even the ones 
without severe signs were slack and duU- 
eyed. They simply lacked the natural 
vivacity of children." 

During repeated trips to Xinjiang, as 
DeLong pursued his initial goal of study- 
ing the impact of iodine deficiency on 
fetal brain development, he pondered 
ways to pre\'ent the calamity from occur- 
ring in the first place. By then he had 
growTi close to two Chinese colleagues. 
Ma Tai, a leading expert on IDD in China, 
and Cao Xue-yi, the head of Xinjiang's 
Health and Anti-Epidemic Station. 
Together they explored — and rejected as 
impractical — possible solutions to the 
seemingly intractable problem. 

Then, one day after working in the 
clinic, the collaborators happened to 
drive to the countryside to see the main 
irrigation dam, 20 miles upstream. "We 
looked out over the Hotien River with 
its complex system of irrigation canals, 
the basis of all human life there," 
DeLong says. "It was fascinating, but I 
didn't give it much thought. Back in the 
capital the next day, I chatted with a 
local water chemist about the concen- 
trations of various minerals, such as 
iron and copper, in the water. But the 
penny still didn't drop." 

That ex'ening, DeLong says, "We were 
driving to a Uighur comedic perfor- 
mance when suddenly it hit me. 1 practi- 
cally shouted, 'We can drip potassium 
iodate into the irrigation water!' Dr. Ma 
threw up his hands and cried, 'We'U all 
go to jail!' But by the next day, he was 



thinking about it seriously. It quickly 
became clear that the idea could work." 

DeLong had realized that iodinating 
the irrigation water could protect entire 
villages. The plants would absorb the 
iodine that had leached from the treated 
water into the soil. The animals, in turn, 
would ingest the iodine-rich plants. At 
the top of the food chain, people would 
finally consume sufficient levels of iodine. 

Obtaining approval for his proposal 
from suspicious local communities 
would be tricky, DeLong knew. But an 
incident that had taken place the pre\i' 
ous year had helped comince the wider 
Uighur community of the physician's 
good intentions. 

Late one afternoon DeLong, Ma, and 
their team were working in a small clinic 
in the village of Tusala when a sandstorm 
swept in from the desert. DeLong's wife, 
Nancy, who has shared his IDD work at 
every stage, recalls that day. 

"About three o'clock the room sud- 
denly became almost as dark as night, 
with an eerie yellow hght," she says. "A 
gale force wind was blowing the trees 
sideways and sending dust swirls sky- 
ward. The patients covered their mouths 
and noses with their headscarves and 
huddled along an inside corridor. The 
lights flickered and went out." 

Just as the medical team had begun 
examining patients again, a great com- 
motion of people burst into the room; 
they were bringing in a young boy who 
had picked up a live cable blown down 
by the storm. For several long minutes 
DeLong desperately tried mouth-to- 

mouth resuscitation and chest compres- 
sions but could get no response. Then 
someone mentioned that the boy's father 
had transported him to the cUnic in a 
donkey cart for six kilometers. 

"I shined a Ught into the boy's eyes," 
Nancy DeLong says. "He was dead. Bob 
straightened up, told the father he was 
sorry, and stood helplessly in tears, as the 
father, fighting for control, gently hfted his 
child, wTapped a sheet — now a shroud — 
around him, and carried him from the 
room, clasped tightly to his breast." 

"Tragically, our sustained efforts 
couldn't revive the boy," Ma later 
recounted, "Yet his family bent down to 
express their heartfelt gratefulness. .And 
the story about the American doctor 
spread, even to the capital." 

The reser\'oir of good will that DeLong 
generated that day may ha\'e helped his 
cause when, a year later, he and his team 
explained the proposal to iodinate the 
irrigation water to \illagers in the cho- 
sen site of Long Ru township. Each 
phrase was painstakingly translated into 
Mandarin, then into Uighur. To the team 
members' rehef, they found a recepri\'e 
audience. The villagers discussed the 
dilemma, then took a vote. 

"When we met with the \illage lead- 
ers in Long Ru, the temperature was ho\'- 
ering near zero," remembers Nancy 
DeLong. "They were all sitting around in 
their thin coats and wool hats. Their 
breaths sent tiny clouds into the air and 
their wonderful weathered faces looked 
like stone. Then suddenly everyone 
erupted; 'Yes, we approve!'" 


MINERAL RIGHTS: Parents with cretinism 
gave birth to a healthy daughter, thanks 
to the introduction of iodized salt in 
southcentrol China several years earlier 
(top); a Uighur father cradling his child 
in Xinjiang (above); a sheep herder in 
the dusty Taklimokan Desert (right) 

All Hands to the Pump 


In 1854, anesthesiologist John Snow solved the mystery of a 
fast-moving, deadly cholera epidemic in London, one he later 
termed "the most terrible outbreak of cholera vv'hich ever 
occurred in the kingdom." On the night of August 31, resi- 
dents scattered across a Soho neighborhood fell violently ill. 
Within three days, 127 people had died. A week later, the 
toll had risen to 500. 

From the start Snow interviewed the families of victims, reviewed 
death records, and walked the neighborhood, seeking patterns. His 
suspicions soon centered on the Broad Street water pump. The clues 
quickly accumulated: many of the victims lived near the pump, and 
the closer people lived to another pump, the less likely they were to 
have contracted cholera. None of the workers in a nearby brewery, 
where the men drank free beer rather than water, grew ill. And only 



The Bottom of the Barrel 

One of the first tasks facing DeLong's 
team was calculating the flow rate of the 
canal. Impatient for the arrival of outside 
help, DeLong drew on his youthful pen- 
chants. In the eighth grade he had taken 
an interest inventory test that recom- 
mended he become a county agricultural 
agent. So it was with a sense of familiari- 
ty that he tackled the challenge. 

"We stripped to our undershorts, 
waded into the canal to measure its 
cross-section, then threw sticks in the 
water and recorded how fast they 
floated by," DeLong says. "I felt like I 
was back on my uncle's farm in Indi- 
ana, tossing twigs into the creek. Much 
later, we learned that our estimate 
was within 10 percent of the official 

The team next devised a primitive 
deUvery system: a 55-gallon oil drum 
coated with epoxy paint to prevent oxi- 
dation and rigged with a spigot that 
could be turned on and off. The spigot 

was not precise 


in regulating 

the output, though, so they used intra- 
venous tubing and two clamps to cob- 
ble together a simple valve to provide a 
steady flow. They tested their contrap- 

a handful of the 530 inmates of o local workhouse — which had its 
own pump — became sick. One clue confounded Snow, though: the 
death of a widow who had not visited the neighborhood for years. 
Then an interview with her son revealed that the woman had indulged 
a daily habit of dispatching a servant to the Broad Street pump, for 
she preferred the taste of its water. Snow convinced the local parish to 
remove the handle from the pump, and the epidemic subsided. 

John Snow would recognize in Robert DeLong a kindred spirit. 
In the one instance a physician proved that water was a lethal 
threat; in the other, water became a life-sustaining force. By solv- 
ing seemingly intractable problems with ingenuity and persever- 
ance, DeLong became, in the tradition of John Snow, an excel- 
lent example of what an individual doctor can accomplish for 
the public good. ■ 





tion overnight in a hotel parking lot — 
and found that it worked. 

Next they perched the oil drum on a 
wooden bridge spanning the irrigation 
canal. For two weeks during the spring 
of 1992, the team dripped a 5 percent 
solution of potassium iodate into the 
canal, which supplied four villages in 
Long Ru township with water. They 
hired a local villager to protect the drum 
from theft, refill the tank, and monitor 
the flow rate. At night, the man would 
unfurl his roUed-up blanket and sleep 
right on the rough-hewTi bridge. 

Soon more men were needed to safe- 
guard more barrels. Decisions about the 
placement of the drums and the timing of 
the dripping were made with the input 
of local officials, particularly the kiiaiji, 
or water accountants, who oversaw all 
aspects of irrigation for the region. During 
the spring planting, as many as 20 tank- 
fuls of potassium iodate solution were 
dripped into a canal from a single site. 

The Taste of Success 

Measurements from samples sent to a lab- 
oratory in Urijmqi, the capital, revealed 
that iodine concentration in treated areas 
had increased four- fold in the soil within 
weeks and three-fold in the crops and ani- 
mals within months. Within one year, 
nearly all local women of childbearing age 
had iodine levels well out of the danger 
zone. The results were most dramatic 
in children conceived after the program 
began. Within three years of the first drip 
ping, the infant mortality rate fell by half. 


Later assessments showed that the a\'er- 
age height of fi\'e-year-olds had increased 
by four inches. And the intelligence quo- 
tients of children born after the dripping 
averaged 16 points higher than those of 
children born before the dripping. 

"When we first arrived in Xinjiang, I 
thought the children were withdrawn 
because they were afraid of us," says 
Nancy DeLong. "But as time passed, and 
the treated water took effect, I realized 
that the children were growing li\'eher." 

Local livestock thrived too. Within a 
year, sheep production had increased by 
40 percent. And as a result, the average 
annual family income rose 5 percent. 

From their mitial study, published m 
1994, DeLong and his colleagues conclud- 
ed that treating irrigation water was 
an effective and relatively inexpensive 
method of supplying iodine to people in 
irrigated areas where IDD is endemic. 
With the support of the Thrasher Foun- 
dation, the Joseph P. Kennedy, Jr. Founda- 
tion, Kiwanis International, and UNICEF, 
the team undertook a major expansion of 
its program in 1997. Iodine dripping now 
protects 2.6 rrulhon people from IDD in 
the 16 most se\'erely deficient areas of Xin- 
jiang. Thirteen and one half tons of potas- 
sium iodate ha\'e already been dripped, 
at a cost of less than six cents per person. 

A Giant Leap for Mankind 

Robert DeLong's interest in IDD stemmed from his experience 
as a pediatric neurologist at Massachusetts General Hospital, 
where he met John Stanbury '39, then chief of the hospital's 
thyroid service and a professor of nutrition at MIT. Stanbury, 
already renowned for his pioneering studies of inherited 
metabolic disease of the thyroid, had widened his interests 
to encompass the international problem of IDD. 



SCENES FROM SIBERIA: Nomadic horse- 
men rest near a lake in Tuva (left); a 
girl peers out of a window of the Tos 
Deer Shaman Association in Tuva 

Iodine concentrations in soO, crops, 
meat, and human urine, monitored since 
the one-time dripping, indicate that a 
single dripping can p^o^•ide iodine for at 
least six years. lodination of irrigation 
water has now been undertaken in Inner 
MongoUa and is planned for Kyrgyzstan. 

The Saline Solution 

But what about iodine deficient areas 
of the world where widespread irriga- 
tion doesn't exist? In the heart of 
Siberia, at the geographic center of Asia, 
lies Tuva, the poorest republic in Russia. 

Home to a Mongolian people, Tuva is 
renowned for its rich folklore, skilled 
artisans, and khoomci, a form of throat 
singing whose haunting notes are said 
to mimic the wind sweeping across the 
steppes. The area is also known for its 
elevated rates of IDD. 

There infant mortality runs high, and 
in some areas nearly half of the newborns 
have hypothyroidism caused by iodine 
deficiency The lasting economic disrup- 
tion that followed the collapse of the 
Soviet Union has made iodized salt an 
impractical solution. .\nd, unlike the peo- 
ple of Xinjiang, the Tuvans do not rely on 
irrigation water. They depend instead on 
animal herding for their hvelihood, rais- 
ing sheep, cattle, horses, goats, and even 
camels on the elevated steppes of their 
ancestral homeland. 

When DeLong reflected on the high 
rates of se\'ere IDD in Tuva, he reasoned 
that the most efficient way to distribute 
iodine would be by adding potassium 
iodate to salt hcks for the animals on 
whose products — mutton, beef, milk, 
cheese, and yogurt — the people reUed. 
"We knew," he says, "that iodinating salt 
hcks had been successful in the Nether 
lands and England, where the iodine lev- 
els in cows rose dramatically." 

The plan required machinery for 
crushing rock .salt, adding iodate, and 
making salt blocks. The Tuvan govern- 
ment approN'ed the plan and promised to 
supply the potassium iodate and workers 
to operate the plant. Local authorities 
agreed to distribute free iodinated salt 
blocks to all herders in the region. 

But the machinery still needed to be 
financed, manufactured in India, and 
transported by ship, the Trans-Siberian 
railway, and truck to Tuva. And all this 
had to be arranged from half a world away. 
DeLong secured financial support from 
friends and members of Kiwanis Interna- 
tional. By the fall of 2002 the machinery 
had arri\'ed. So DeLong returned to Tuva 
with his Kiwanian friends. 

"One of them was a high school 
mechanical shop teacher," DeLong says, 
"and he had that machine up and running 
in two days." By the time the Kiwanians 
staged a repeat \'isit the following spring, 
local workers were turning out iodinated 
salt blocks and distributing them to 
Tuva's mountain communities. 

"Their sheep had been producing 
poor quality wool because of the lack of 
iodine," DeLong says. "If we're lucky, the 
salt licks should improve not only 
human health, but also the health of the 
local wool industry." 

DeLong and his team hope that, as 
knowledge of the health benefits, afford- 
ability, safety, and economic advantages 
of iodinating irrigation water and salt 
licks spreads to affected areas of the 
world, so will the adoption of their prac 
tical methods. "With all the medical 
technologies we have to work with 
today," DeLong says, "it's easy to forget 
the incredible difference an ancient 
trace mineral can make to a single life, to 
a community — even to the world." ■ 

Gordon Worhy '73 is an associate clinical profes- 
sor at the Duke University School of Medicine. 


At a time when IDD received little attention in the United States, 
Stanbury recognized that it remained a severe problem in many 
parts of the world and that its crux was not goiter, but rather curtail- 
ment of brain growth, resulting in mental retardation and, at the 
extreme, endemic cretinism. He also recognized that IDD increased 
rates of miscarriage and infant mortality. His leadership led to his 
being named chairman of the International Council for the Control 

of Iodine Deficiency Disorders at its inception in 1986 and to his 
receiving the prestigious Prince Mahidol Award seven years later. 

"John had the imagination to recognize that IDD, which was 
considered anachronistic in the United States, was still a massive 
burden to people in many parts of the world," DeLong soys. "And 
he has led and inspired many others to work for the elimination of 
this critical problem. He's a giant in the field." ■ 



the imaginations of researchers dedicated to unraveling the mysteries of sleep disorders 




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Peter Bent Brigham Hospital, he was packing 263 pounds onto his 
five-foot-five-inch frame. For as long as he could remember, the 
man explained, he had been overweight, but now he had an 
alarming new set of problems to go along with his obesity. 

by Peter V. Tishler 


"The object that presented itself to the eyes of the astonished clerk 

Overeating in response to a series of "anxieties and 
frustrations" had caused the man to gain nearly 70 
pounds in less than a year, his physician, C. Sidney 
Burwell '19, noted in a 1955 case report. As the patient's 
girth increased, so had his symptoms of fatigue, short- 
ness of breath, and swollen ankles. But the man's 
acknowledgement of the high stakes of his condition — 
and the event that propelled him to the hospital exam- 
ining room — took place during a poker game. 

In the year preceding his hospital admission, Burwell's 
report observed, the man had occasionally fallen 
asleep — sometimes hterally on his feet — while carrying 
on with his daily routine to the point that "he sometimes 
found it difficult to distinguish between reality and 
dreams." The final straw came when the patient dozed off 
during his weekly poker game, waking too late to take 
advantage of the extraordinary hand he had been dealt — 
three aces and two kings. And yet the patient's squan- 
dered fuU house may have saved his life. 

What the Dickens 

Burwell, who served as dean of HMS from 1935 to 1949, 
may have been the first cUnician to recognize the rela- 
tionship between the poker player's obesity and his 
hypersomnolence. As a researcher for many years and 
later as the first Samuel A. Le\'ine Professor of Medicine 
at HMS, Burwell maintained laboratories at the Peter 
Bent Brigham Hospital and the Boston Lying-in Hospital. 
He was involved in obesity research at both institutions. 

In addition to his research and teaching activities, 
Burwell maintained a clinical practice that focused, in 
part, on annual physicals of business executives. The 
obese 51-year-old patient whose case would ultimately 
inspire Burwell to write an article on what he labeled 
the "Pickwickian syndrome" — or morbid obesity asso- 
ciated with falling asleep at inappropriate times — ^was 
such an executive. 

In writing up the case, Burwell and his colleagues 
drew a parallel between the patient and a fictional char- 
acter, Joe the Fat Boy from Charles Dickens's 1837 novel, 
originally serialized as The Posthumous Papers of the Pickwick 
Chih. In his article Burwell set the stage for naming the 
syndrome by im'okingjoe: 

A most violent and startling knockingwas heard at the door . . a 
constant and uninterrupted succession of the loudest single raps. . . 

The object that presented itself to the eyes of the astonished clerk 
was a hoy — a wonderfully fat hoy — habited as a sen-ing lad, stand- 
ing upright on the mat, with his eyes closed as if in sleep. . . 

"What's the matter^" inquired the clerk. 

The extraordinary boy replied not a word; hut he nodded once, 
and seemed, to the clerk's imagination, to snore feebly. 

"Where do you comefromr inquired the clerk. 

The hoy made no sign. He breathed heavily, but in all other 
respects was motionless. 

The clerk repeated the question thrice, and receiving no answer, 
prepared to shut the door, when the boy suddenly opened his eyes, 
winked several times, sneezed once, and raised his hand as if to 
repeat the knocking. Finding the door open, he stared about him with 
astonishment, and at length fixed his eyes on Mr Lowtcn'sface. 

"What the devil do you knock in that way for?" inquired the 
clerk, angrily. 

"Which way?" said the hoy. in a slow and sleepy voice. 

"Why. like forty hackney coachmen," replied the clerk. 

"Because master said, I wasn't to leave off knocking till they 
opened the door, for fear I should go to sleep," said the boy. 

Burwell's connection between hypersomnolence and 
the Dickens novel displeased an editorialist in the New 
England Journal of Medicine, who countered that the 
syndrome should be called Fat Joe's Folly. 

Naming Rights 

The notion that Burwell and his colleagues were the first 
to recognize and describe the Pickwickian syndrome 
and to link it with Dickens's character is only one of sev- 
eral erroneous ideas surrounding the syndrome. The 
first clinical description may actually have been written 
almost two centuries before Burwell brought it to wide 
attention. In the same year in which the American 
colonies declared their independence from Britain, the 
physician John Fothergill reported on two obese 
patients from his London practice, both of whom exhib 
ited classic symptoms of the syndrome. In one patient, 
Fothergill wrote, the manifestations of the disease even- 
tually remitted with weight loss. 

From the early 1800s up through the 1950s other physi 
cians recorded cases similar to FothergiU's. The common 
denominators in their descriptions were obesit)' and hx'per 
somnolence. But some of them also noted features such as 
cyanosis, polyc)themia, and right heart failure. And, just as 
the s)Tidrome itself was not new to the medical literature. 



Bunvell's invocation of Dickens in his 

naming of it also had precedent in the past, hi 
fact, the svTidrome had first been hkened to the phenotN'pe 
of Joe in The Pickwick Papers as early as 1889, by Christopher 
Heath, then president of the Clinical Societ)' of London. 

A little over a decade after Heath made his Dickensian 
connection. Sir W'ilham Osier, writing in the fourth edi 
tion, pubhshed in 1901, of his classic text, The Principles and 
Practice of Medicine, noted that "an extraordinary phenom- 
enon seen occasionally in excessi\'ely fat young persons is 
an uncontrollable tendency to sleep." In the sixth edition, 
published in 1905, he added the phrase "hke the fat boy in 

Pickwick." Osier was aware of 
prior case descriptions of the phe- 
nomenon and probably also knew that Heath had already 
im'oked the likeness of Joe in The Pickwick Papers. Similar- 
ly, Byrom Bramwell, a British physician, described, in 
1910, a boy who "presents in a minor degree a condition 
similar to the Fat Boy in Pickwick." 

Singular Sensation 

On November 14, 1955, Burvvell presented a paper before 
the New England Cardiovascular Society entitled "A 



Pickwickian Syndrome," in which he described his 
poker pkaying patient. Two weeks Later, he spoke at an 
American Medical Association meeting held in Boston. 
The presentation, entitled "The Care of the Patient," 
sought to reconcile the practice of contemporary medi- 
cine with the ideals Francis Peabody '07 expressed in his 
famous essay of the same title. Burwell used the descrip- 
tion of his patient to focus on the "general objectives of 
medicine. . .to use the science of medicine; to use the art of 
medicine; and to exploit the inborn and ready-made skill 
of the experienced human organism." 

One year later Burwell published, as lead author, the 
complete case report on his patient with the Pickwickian 
syndrome in the American Journal of Medicine. The "careful 
study of one patient," Burwell's article explained, would 
provide a basis to "consider the association of obesity. 

somnolence, polycythemia, and excessive appetite." The 
paper included quotes from Dickens's The Pickwick Papers 
and a reproduction of Thomas Nast's drawing of Joe, 
from an 1873 American edition of the novel. 

Whether Burwell possessed any knowledge that oth- 
ers before him had appUed this analogy is uncertain 
because neither Robert Whaley nor Eugene Bickelmann, 
two of his coauthors, e\'er heard him discuss his patient in 
relation to Dickens's character. His coauthors do remem- 
ber, however, that he was fond of the classics. Whaley also 
recalls that physicians often described BurweU's pubhca 
tion and the naming of the syndrome as "cute." 

But the whimsy of the name did not detract from the 
seriousness of the condition it described. In their paper, 
Burwell and his coauthors outlined the clinical features 
of the Pickwickian syndrome. These included marked 

rdinary Joe 

Physicians had been noting a 
connection between obesity 
and unusual sleepiness as far 
back as the days of the Amer- 
ican Revolution. So why did 
the report by Burwell and his 
colleagues, written almost two 
centuries later, generate so much atten- 
tion, both nationally and internationally? 
Peretz Lavie, a sleep physiologist in 
Israel, has pointed out that the Pick- 
wickian syndrome, as well as other 
sleep disorders, suffered from a wide- 
spread perception in the nineteenth 
and early twentieth centuries that exces- 
sive somnolence was inconsequential. 
Another prevalent — and erroneous — 

THE BIG SLEEP: C. Sidney Burwell 
helped highlight the connection 
between somnolence and obesity. 



at young persons is on uncontro la 

to slee 

obesity; somnolence; cyanosis; twitching (probably the 
myoclonic jerks/asterixis seen in association with hyper 
carbia); periodic respiration ("periods of apnea alternat 
ed with periods of tachypnea"); secondary polycythemia; 
right ventricular hypertrophy; and right ventricular fail- 
ure (neck vein distention, hepatomegaly, and peripheral 
edema). The authors did not im'estigate the patient's 
breathing during sleep. 

Fortunately, Burwell and his colleagues reported, with 
weight reduction the patient's "somnolence, twitching, 
periodic respiration, dyspnea, and edema gradually sub- 
sided and his physical condition became essentially nor 
mal." They postulated that the patient's obesity had led 
to shallow respiration, possibly resulting from the 
increased strain of breathing. Continued shallow respira 
tions, they speculated, had ultimately led to alveolar 

hypoventilation, with resultant hypoxia, hypercarbia, 
and other clinical manifestations. 

On the Right Track 

In the late 1950s clinicians identified many patients with 
the Pickwickian syndrome. In 1959, when Burwell was 
the di,scussant at a Cabot Conference at Massachusetts 
General Hospital, he mentioned that he had studied a 
dozen patients v\ith the syndrome. Medical students and 
faculty who were at the Brigham at the time report that 
they were familiar with the syndrome, as were those 
working at Boston City Hospital with the Har\'ard Med 
ical Services in the mid 1960s. 

Early in the next decade, a number of pulmonary phys- 
iologists developed polygraphic methods to study 

notion was that such cases represent- 
ed a form of narcolepsy. Both ideas 
may have discouraged further interest 
in the syndrome. 

But larger answer may lie in the 
times. In the 1 950s, many developed 
nations were enjoying renewed pros- 
perity after the tribulations of the Great 
Depression and World War II. Food 
was now plentiful and affordable. 
Industrial mechanization hod continued 
apace, with the result that large seg- 
ments of the population engaged in 
less physical activity. These changes 
combined to produce the beginning of 
the obesity epidemic so clearly evident 
in today's society. 

These trends also coincided with the 
beginnings of major, rapid advances in 
medical science; a burgeoning research 
effort aided by the infusion of National 

Institutes of Health funding; and 
renewed postwar training of physicians 
and scientists. The critical role of com- 
munication in the medical sciences, rep- 
resented by the circulation of journals of 
reliable quality, was ascendant. Thus, 
an article in the American Journal of 
Medicine, a highly respected publica- 
tion with worldwide circulation, would 
attract notice. Burwell's paper appeared 
at the right time and in the right place. 

It did not hurt Burwell's cause, 
either, that tongue-in<heek editorials 
taking issue with the naming of the 
syndrome or some aspect of the 
description were printed in other 
visible publications. Further publicity 
arose from the lay press. In 1958, the 
medio reported widely on the trial of a 
colorful gambling kingpin by the name 
of "Sloppy Joe" Bellinger. Sloppy Joe 

was infamous for running numbers, 
whiskey, and women in Savannah, 
Georgia — and for weighing in at 425 
pounds. Yet his day in court was 
repeatedly delayed because the defen- 
dant kept falling asleep each time he 
was asked a compromising question. 
Sloppy Joe's attorney, Ralph Craw- 
ford, succeeded brilliantly in preserving 
his notorious client's freedom by invok- 
ing Sloppy Joe's uncontrollable urges to 
snooze as a hopeless impediment to 
preparing a defense. Crawford's argu- 
ment was buttressed by Bellinger's 
court-appointed physician, who con- 
cluded that Bellinger could not be fair- 
ly tried until he shed at least 200 
pounds. "The Pickwickian syndrome!" 
Crawford would cry out, before 
admonishing the judge and frustrated 
prosecutors. "Read your Dickens!" ■ 


So hefty was Taft, who stood just under six feel 

breathing that presaged the modern laboratory poly- 
somnogram. These reproducible and quantitative meth- 
ods were an essential step that led to the observations 
that apneas are important, that they occur independent- 
ly of any change in alveolar or arterial carbon dioxide 
content, and that the arterial partial pressure of carbon 
dioxide is normal in most people whose sleep is dis- 
turbed by abnormalities of breathing. 

In 1973, Christian Guilleminault, Frederic Eldridge, 
and William Dement at Stanford used this technology 
to describe a new syndrome, which they named sleep 
apnea. We now understand that Pickwickian syndrome 
is but one of the many manifestations of this more gen- 

eralized disorder of breathing during sleep. The mecha- 
nism that Burwell and his colleagues had postulated 
was wrong, since they did not have the data that estab- 
lished apneas as the primary event. As Barbara Morgan 
and Clifford Zwillich observed in 1978, convincing proof 
of this comes from the observation of a sleeping patient 
struggling vigorously to breathe e\en as there is no air- 
flow at the mouth and nose. 

Nonetheless, the case report by Burwell and his col- 
leagues initiated a process in the exploration of sleep dis- 
orders that continues today We now know that sleep 
apnea affects a significant portion of the U.S. population, 
for example, and it may e\'en ha\e played an important 

Dream Team 

Burwell's coauthors on the 
landmark paper on the Pick- 
wickian syndrome were the 
entire professional member- 
ship in his cardiopulmonary 
research laboratory at the 
Peter Bent Brighom Hospi- 
tal — Eugene Robin, Robert Whaley, 
and Albert Bickelmann. 

Of them, Robin, who died in 2000, 
hod the greatest interest and expertise 
in respiratory physiology. At the time of 
the investigation, he was a junior facul- 
ty member at the Brigham, where he 
had established the pulmonary function 
laboratory and was director of the Bur- 
well research laboratory. His studies of 
Burwell's poker-playing patient focused 
on measures of pulmonory function and 
respiratory control. He also did most 
of the writing of the manuscript. Robin 
moved to the University of Pittsburgh in 
1 959 and then to Stanford in 1 970, 
where he continued his pulmonary 

physiology research, pulmonary and 
critical care medical practice, and 
advocacy for patient rights. 

Whaley and Bickelmann were clinical 
fellows with Burwell. Whaley, a pilot with 
a great interest in gadgets, developed 
and maintained the pulmonary function 
equipment for measuring lung volumes, 
diffusion capacities, dead space, and 

alveolar ventilation. He decided, after a 
year and half at the Brigham, to return to 
Anchorage, Alaska, where he had lived 
previously while in the Public Health Ser- 
vice. Whaley remains in Anchorage, 
where he is now retired after a decades- 
long practice of primary care medicine. 

Bickelmann described the clinical 
syndrome and cored for the patient. He 
worked only a single year with Burwell 
before returning to his native Buffalo. 
He spent most of his professional life in 
industrial medicine before retiring in 1991 . 

"The patient was a quiet man," 
Bickelmann recalls, "but he certainly 
expressed his relief when we got to the 
bottom of his symptoms, which disap- 
peared with a weight loss program. At 
the time we had no idea we were setting 
the stage for future research. It's been 
wonderful to see how our work helped 
inspire others to pursue new treatments 
for sleep disorders, which have caused so 
many problems for so many people." ■ 


tal , that he once got stuck in the White House bathtub. 

President Taft was 
noted for his ten- 
dency to doze off 
at odd moments. 


,{ ■' 

role in our country's history, as suggested by cardiologist 
John Sotos's recent article in Cficst on the leadership of 
President William Howard Taft. 

Sotos reports that, not long after taking his oath of office 
in 1909, Taft, who had struggled with a weight problem 
throughout his life, enthusiastically wTrote, "I have lost that 
tendency to sleepiness which made me think of the fat boy 
in Pich\ic]i My color is ver)' much better and my ability to 
work is greater." Yet Taft's optimism would pro\'e short 
lived. The stresses of life in the White House helped ensure 
that his presidential weight never dipped below 300 and 
ranged as high as 340 pounds. 

So hefty was Taft, who stood just under six feet tall, 
that he once got stuck in the White House bathtub. 

much to the merriment of the nation's press. After 
that incident, he called in plumbers to install a 
new tub spacious enough to accommodate four 
men. Size was not Taft's only unusual feature; he 
had an astonishing tendency to doze off in the 
midst of mourning at funerals, attending the 
opera, signing papers, re\'iewing troops, and even 
chatting with dignitaries. To rouse his boss from 
these embarrassing lapses, one of Taft's aides 
rehed on a range of tricks from surreptitious 
pokes to feigned coughing fits. 

To Sotos, Taft's well-documented obesity, 
snoring tendencies, and odd behavior add up to a 
likclv diagnosis of sleep apnea. It is unclear 
w hcther the resulting impairment contributed to 
the widespread perception of the Taft presidency 
as one of the least successful in American politi 
cal history. But it is known that, shortly after 
lea\'ing office, Taft went on a physician-super- 
vised regimen that enabled him to shed perma- 
nently more than 60 pounds. As his excess 
weight disappeared, so did his hypersomnolence, 
and he went on to enjoy a distinguished nine- 
year career as chief justice of the Supreme Court. 

Current research continues to probe the origins 
of and remedies for sleep disorders. Some recent 
efforts ha\'e suggested that such disorders may 
c\'en be inherited. In la)'ing the groundwork for 
these contemporary investigations, Burwell and 
his colleagues identified an important phenome- 
non that extended well beyond "Fat Joe's Folly." ■ 

Peter V. Tishkr, MD, is associate professor of medicine at 

HMS in the Genetics Division and Channing Laboratory. He recalls 
being familiar with the Pickwickian syndrome when he was a house 
officer on the Hanard Medical Senices at Boston City Hospital in the 
midl960s. He hopes to hear from anyone with experiences to add to 
this story and offers his willingness to supply references, upon request 
He can he reached atpcter.tishler@channing.harvardedu. 

The author wishes to thank Albert G. Bickclmann and Robert D. 
Whale y for their enthusiastic response to his interest in their lives; 
George M. Bernier,]r '60, Curtis Prout '41, George W. Thorn, and 
H. Richard Tyler for further information about the 1950s at HMS; 
PerctzLavie for his thoughts; and the staff members of the Depart- 
ment of Rare Books and Special Collections at the Francis A. Count- 
way Library of Medicine for their invaluable assistance. 



A physician and the Navajo 

community she serves struggle 

to make sense of each other's 

blessings and imperfections 



arm in arm through the emergency 
department door, I couldn't tell which 
was to be my next patient. Both were tra 
ditional elders, called shima, or "grand- 
mother," according to a Navajo sense of 
respect. Their faded veh'eteen blouses, 
turquoise bracelets, flowered scarves, 
and gathered skirts harked back to the 
early 1900s. Neither spoke EngUsh. 

One of the nurses helped the sUghtl\- 
more frail of the two onto a hospital gur 
ney. The shima looked up at me with milky 
black eyes. "She's feeling somehow," the 
nurse, who spoke Na\ajo, explained. 

When I had first heard that cryptic 
phrase, soon after moving to the Na\ajo 
Reser\'ation several years ago, I had no 
idea what to make of it. "'She's feeling 
somehow?' What does that mean?" The 
nurse had simply shrugged and repeat 
ed her literal translation, leaving it to 
me to discern what "somehow" could 
possibly signify. Since then, I've heard 
this phrase over and o\'er, and I've 
learned that it could harbinger anything 


A Curse and a Blessing 

Sienna. Auburn. Burnt orange. These used to 
represent nothing more to me than the exotic hues 
in a 64<ount box of Crayola crayons, or the color 
choices I mulled over in the J. Crew catalog. But since 
moving to northern Arizona, these colors have new 
power. The redrock hills behind my house, bleached 
dusty brown by the searing noon sky, give off an 
enveloping rose glow when I walk at dusk. The imposing mesas 
stand golden in the distance as they catch the sun, gradually fading 
to deep violet-gray. Even the meager waters of the San Juan burn at 
sunset as the river winds through the chapped red cliffs. 

The high desert of the Navajo Nation covers an area the size of 
West Virginia and sprawls across Arizona, Utah, and New Mexico. 
Life on the reservation is spore. Nearly half the people live without 
running water or electricity and most have no phone. 

The gulf between the medicine I have to offer and the tradition- 
al lifestyle that many of my patients lead can be overwhelming. 
To complicate the issues, we have inherited a deeply troubled his- 
tory. U.S. government officials displaced Native Americans from 
their lands. They forced Indian children into overcrowded, unsani- 
tary schools, where measles epidemics killed many of them. They 
cut off the boys' braids and washed their mouths out with soap 
when they spoke their native language. The introduction of West- 
ern medicine to the reservation followed a similar path. Well-inten- 
tioned physicians, convinced of the superiority of their therapies, 
tried to beat the medicine men out of existence. 

The Navajo consider words to be powerful because they 
believe each person is part deity. If you warn of the potential for 
a negative outcome, you can, they believe, will the event to hap- 
pen. This conviction mokes discussing treatment options difficult. 

Several months after my husband, Carlos Lerner '98, and I 
moved here, a 59-year-old Navajo man came to our emergency 
department complaining of chest pain. An EKG confirmed a 
major heart attack. But the man refused all treatment. 




from a simple cold to a life-threatening 
heart attack. 

Through the interpreter the 75-year' 
old daughter explained that her mother 
had been feeling weak for se\'eral days 
and that the arthritis in her right leg was 
paining her. The last time she had come 
to the chnic, her mother had received I\' 
fluid that she thought had made her 
stronger, and she might need that treat- 
ment again. "Does your mother feel sick?" 
I asked. "Is she ha\ing trouble breathing? 
Is she getting better or worse?" 

"I don't know," her daughter replied. 
"She's just somehow." 

My questions were only frustrating 
them, so I began an intensive investiga- 
tion that included blood and urine tests. 
I ga\'e the patient the I\' fluid her daugh 
tcr had requested. But, after more than 
two hours in the emergency department, 
all the tests were negative, re\'ealing no 
explanation for why the mother was feel- 
ing somehow. Just as I was ready to dis- 
charge my patient, her daughter pulled 
a bottle of codeine pills out of her purse. 

"She's been taking a lot of these lately," 
she said. "I think they're making her 
weak." After extensive and unnecessary 
testing, our mystery was solved. 

The Na\'ajo approach to illness is fun- 
damentally different from my own med- 
ical tradition. Many of our patients, both 
traditional elders and those from younger 
generations, pursue Nawajo and Western 
medicine concurrently. Without any 
questioning, the medicine men observe a 
patient, discern the problem, and pre- 
scribe a particular ceremony to restore 
spiritual harmony and health. When I 
first arrived on the reser\'ation, I was 
instructed not to take a separate history, 
as I was used to doing, but instead to 
scatter my questions throughout the 
physical exam. This would be more famil 
lar, more like a medicine maris approach. 

The Navajo have a broader concept 
of illness than most. They may attribute 
their problems to a skin walker — an 
embodiment of an evil spirit that has 
caused them harm — or to a snake that 
crossed their path many summers ago. A 

fall suffered as a child can carry great sig- 
nificance to an elder with abdominal 
pain. Few elders view an illness as a dis- 
crete episode in an otherwise healthy 
life. They always trace connections to 
past events and conflicted spirits. 

Not long after moving to the reserva- 
tion, I e\'aluated a 60-year-old woman 
with abdoiTunal pain hkely caused by gall- 
stones. It was after hours, so I told her that 
we could not perform a diagnostic ultra- 
sound until the following morning. The 
woman became enraged. "What kind of 
doctor are you anyway, that you can't do 
the test? That you can't tell me whether 
or not I have gallstones? I bet you didn't 
e\'en graduate from medical school!" 

Her hu.sband chimed in. "You mean to 
tell me you can't gi\'e no pills or nothing 
to take away the gallstones? This is bull 
shit!" he snarled as they stormed out. My 
Western medicine had failed to meet 
their Navajo expectations. 

"Don't worry," the nurse murmured 
after they left. "I know them, and they're 
always like that." ■ 


Carlos tried to convince him to stay: "Some people with heart 
attacks can have serious problems," he warned. "I strongly recom- 
mend that you allow us to transfer you to the hospital." 

The man simply pushed past him and headed for the door. A 
nurse tried to intervene. "I know that this is taboo in your tradition," 
he said, "but I have to tell you that if you don't accept treatment you 
could die. I don't wish it on you, but you have to know that." The 
man burst out the door. 

Less than six hours later, we were awakened for a code blue 
in the emergency department. It was the same patient. He had 
become unconscious at home. The ambulance drove 30 minutes at 
top speed over dirt roads to reach him and another 40 to bring him 
back to the clinic. By the time he arrived, we could not save him. 

Afterward, Carlos agonized that he had not been explicit 
enough. "We can use the excuse that we need to respect their trad 
tions to avoid the hard conversations," he said. "Maybe I should 
have said more than I did." 

The painful history of white intervention on the reservation 
hangs heavy in the air. If we did not shore this past, I would feel 

comfortable voicing my opinions more forcefully. I would worry 
less that I was compelling my patients to choose "the white way." 
I wouldn't fear alienating my patients, who might believe I have 
contributed to their illness in a misguided attempt to heal. 

Titus, a social worker at the clinic and the Westernized son of 
a medicine man, spoke to our medical staff after the man died. 
"I don't know what the answer is," he said. "Many traditionals 
die in ignorance because they can't see the whole story, the 
way you see it. We are very grateful that you have chosen 
to be with us here on the reservation, to bring your 
talents to care for us." He offered a Navajo 
blessing for us. 

I found his words comforting. If 
Titus didn't know the answer, 
then I had permission to 
struggle, too. ■ 




for fhe years, after hiccoming paralyzed 
in a car accident that I suspected was 
alcohol-related. He wore his unwashed 
hair short on top, while the bottom hung 
in strands to his shoulders. His thick, 
fleshy features had a faint oily sheen, and 
he smelled of urine from his leg bag, 
tinged green from long use and held in 
place with a ratty strip of elastic. 

"Oh, dont ask Johnson," his primary 
care physician warned me when I men- 
tioned that I was thinking of in\'iting him 
to speak to a group of Navajo high school 
students. "He'll be a disaster." 

Although the iNavajo ha\'e chosen to 
outlaw alcohol, it remains a significant 
problem. As physicians, we feel the ebb 
and flow of its monthly cycle. The first of 
the month with its paycheck or benefit 
check brings intoxication and assaults; 
alcohol withdrawal creeps in as funds 
wane toward the end of the month. 

The pattern of alcohohsm is different 
on the "rez" than in other places I have 
worked. No one drinks quietly at home 
in the evenings. Instead, people tend 
to go on dramatic binges, disappearing 

Vanishing Acts 

I was first struck by Casey's long hair as he strode down the 
dim hallway. Most Navajo men with long hair wear it in the 
traditional style, gathered into a tight roll at the nape of the 
neck and bound with yarn. But Casey's coarse hair streamed 
below his waist, waning to uneven, wispy tendrils. He held 
out his right hand in the traditional Navajo greeting, a softer 
version of the all-American handshake. He wore turquoise and 
silver wristbands on each arm, his only nod to traditional dress. 

Casey was not at all what I expected of a medicine man. For the 
most part, they are older men, with their thinning white hair pulled 
tight, clothed in smart Western-style button-down shirts with pointy 
collars and opalescent buttons and pressed blue jeans. 

But Casey looked to be barely out of his twenties, and despite 
his chiseled nutmeg features and penetrating black eyes, he hod a 
quiet softness about him. He was a startling blend of modern and 


traditional. I had invited him to the clinic to speak about tradition- 
al Navajo healing ceremonies to round out an enrichment pro- 
gram introducing local high school students to medicine. 

The ceremonies are complicated and long — some lasting nine 
days and nights, continuously — so most medicine men specialize 
in only one or two. Casey, who practiced the Mountain Way 
Ceremony, said he would be happy to talk to my students. "Our 
children are our future," he said. And since this would not be an 
actual ceremony, he felt it would be all right to take pictures. 
Usually photographs, which create a permanent record, are taboo. 

The following week, Casey entered the clinic's hogan — a tradi- 
tional Navajo dwelling — to give his talk. This time, he had his long 
hair bound in the more traditional bun. He sported more elabo- 
rate turquoise cuffs than he had worn the previous week, with 
jeans, a button-down shirt, and battered work boots. His brother, 
who accompanied him, was heavyset, with a pageboy haircut 
and a large silver cross dangling over his faded black T-shirt. 

Casey believes his ceremonies have cured many patients and 
that the ceremonies, in conjunction with Western chemotherapy. 




from their homes only to reappear in 
emergency rooms across the reservation 
days later, \4ost of the drinkers are men. 
Women tend to stay sober, struggling to 
hold the family together at home. But the 
younger girls are starting to drink just as 
hard as their male companions. 

I'm not sure why so many Navajo 
succumb to alcoholism. Contributing 
factors may be that few jobs exist on the 
rez for men, and the traditional Lifestyle 
is falhng by the wayside. Men have time 
on their hands and desperation — or pos- 
sibly just boredom — in their hearts. 
Until the drinkers are ready to change, 
though, we can do Uttle except identify 
the disease and hope they take action. 

One of my patients laughed at my 
written discharge instructions when he 
finally sobered up enough to leave the ER. 
"Please stop drinking," he read aloud. He 
was still chuckling as he walked out. I 
knew he wouldn't stop drinking just 
because I had written those words, but I 
wanted to acknowledge the primary 
issue that had brought him in that night. 

Johnson wasn't actually my patient, 
although I had seen him severd times in 

the emergency department for urinary 
tract infections. Against my better judg- 
ment, I offered him a $50 stipend to 
spend an hour with my high school stu- 
dents talking about his experience as a 
paraplegic. I didn't expect him to show. 

Much to my surprise, he arrived at the 
clinic a half hour early for his session. He 
had washed his hair and put on a clean 
sweatshirt. He smelled pleasantly of 
aftershave, vvlthout even an undertone of 
stagnant urine. His rickety wheelchair 
was missing one footrest, and he sat 
crooked in the chair with both feet 
crammed on the remaining rest. 

When Johnson spoke to the students, 
he was candid about the role alcohol had 
played in his accident. He and his buddies 
had all been drunk on the night of the 
crash, he said. They rolled their vehicle 
just beyond the only traffic Light in town. 
The front passenger died instantly, and 
Johnson was throwTi from the car. John- 
son had spent the next six months in a 
rehabilitation hospital; the driver was 
ser\'ing a 25-year prison sentence. 

The students were so capti\'ated by 
Johnson's experience that they took it 

upon themselves to write to various agen- 
cies requesting donations to purchase 
him a new racing wheelchair; they knew 
he had enjoyed wheelchair sports during 
rehab. They collected $500 and begged 
me not to teU Johnson their secret until 
they had raised the fuU amount. 

I asked our community health nurses 
for ad\ice about buying a new wheelchair. 
They Lcnew Johnson well and had, in fact, 
obtained a new wheelchair for him just a 
few months earUer. But he had lost it in jail 
several weeks before he met with my stu- 
dents, when he was in detention for pubUc 
intoxication. I couldn't bear to teU the 
class. Instead, I funneled the money into a 
support group for patients with spinal 
cord injuries. They ne\'er raised enough to 
purchase the wheelchair anyway 

In the spring, it was time for Johnson 
to attend his yearly spinal cord chnic. I 
pulled his chart to send him an appoint- 
ment slip, only to learn that he had died. 
He had gone out drinking with his bud- 
dies the previous winter. They had aban- 
doned him, and somehow Johnson fell 
out of his wheelchair. Alone in the win- 
try desert night, he had frozen to death. ■ 

put his mother's advanced breast cancer /i^H^^ 

into remission. When I asked how he felt ^g^^^^Kr 

about performing a traditional rite in the |^^^^^^^ 

heartland of white man's medicine, he said, ^ 

"I go where I need to go. I wont the person 
to have the benefits of the traditional heal- 
ing no matter where they ore. We're an 
adaptable people." 

As Casey talked, his brother would nudge 
him whenever he felt the conversation 
strayed too close to sacred information. "We 

shouldn't talk about that," he would warn. And although Casey hod 
originally agreed to be photographed, when I pulled out the cam- 
era, his brother shook his head. "Even what we've been doing here 
today — including Anglos — and talking about the ancient traditions, 
it's kind of on the edge." 

Casey agreed. "My grandfather asked us, on his dying bed, to 
take a video of the hogan, because what we had would be gone 
within a few generations. Just for the family. But we refused." 


Navajo medicine men 
sand painting in Chin 

Casey believes that the Navajo are losing 
touch with the heart of their culture. "Do you see 
my hair?" he asked, pointing to his bun. "I wear 
it long, in the traditional way. This strand of yarn 
is a sunbeam, and the two ends" — he pointed to 
the rolled edges of the bun — "are clouds. Maybe 
if we all wore our hair long, in the traditional 
way, the gods would smile down on us again 
and treat us kindly." Yet his brother, the more tra- 
ditionally diligent of the two, wore his hair short 
and a cross on his chest. 
Even though I respected his decision, I cringed at the thought 
of Casey refusing to videotape his grandfather's hogan. Casey 
recognizes that the children represent the perseverance of tradi- 
tional Navajo culture. Yet he cannot bring himself to leave the per- 
manent record that would help the old traditions survive without 
the elders. In his eyes, preserving the traditions through modern 
methods risks the heart of Navajo spirituality even as it protects 
the outer shell of the culture. ■ 

perform sacred 
Lee, Arizona. 




otherwise quiet Sunday morning in our 
clinic emergency room on the Navajo 
Reservation. "This guy is burned from 
head to toe," came the breathless 
report. "His face and mouth are all 
black. We'll be at your back door in less 
than two minutes." 

House fires are a chronic danger in our 
area. More than half of our local homes 
lack central heating and rely instead on 
coal' or wood-burning stoves. Some- 
times the consequences are tragic. Last 
winter I learned that one of my three- 
year-old patients, who had introduced 
himself to me as "Pooh Bear," had died in 
a house fire. But deaths are rare. Most 
fires are routine affairs that attract bare- 
ly a passing notice. 

We had just cleared a bed when the 
ambulance pulled up. The medics 
rushed the patient into the ER. "When 
we drove up, he was standing outside," 
the medic said. "His clothes were in 
flames. We put out the fire and ripped 

off the clothes. Then we just scooped 
him and ran." 

The man's entire body was charred. 
The skin on his chest and abdomen was 
starting to peel off in sheets as tender 
blisters ruptured, revealing shocking 
pink flesh below. The soles of his feet 
were similarly burned and peeling. His 
genitals were blackened. His hair was 
singed into tiny, black curls, and his ears 
had melted into shapeless nubs. The 
smoky sweet smell of charred flesh 
quickly pervaded the emergency 
department. The only part of his body 
not black and peeling was his right 
hand, on which he had apparently been 
wearing a glo\'e. 

The man turned milky blue eyes 
toward me as I leaned in to hsten to his 
heart and lungs. "Don't worry, sir," I said. 
"We're going to put you to sleep and gi\'e 
you a breathing tube and pain medicine. 
We're going to take care of you." 

"Okay," he whispered and turned his 

^aze to the ceiling. 


Margins of Error 

She's still sick," the mother told me. It was nearly ten 
o'clock, the end of my evening shift, when the moth- 
er and little girl came to the emergency department. 
The mother was o large woman in threadbare 
sweatpants and a frayed T-shirt that asked, "Got 
Frybread?" Her hair was pulled carelessly into a 
bun with loose ends erupting at all angles. Her 
daughter looked to be four years old. She slept on the gurney, 
twisted in a ball with her fists splayed on either side of her head. 
Her flushed face glistened. 

"I don't know what's wrong, but she's not better," her mother 
said, rolling her chair away from the bed to allow me free access 
to her daughter. She turned her dark eyes on me helplessly. 

I paged through the girl's chart and noted that she had been 
seen earlier that afternoon by one of our other pediatricians and 
diagnosed with a urinary tract infection. She hod been started on 
oral antibiotics and sent home. 

"Is she still having pain when she urinates?" I asked the mother 

"I think so. She doesn't want to pee, and she cries." She had 
also thrown up a few times that evening. 

I quickly examined the girl, trying not to wake her. When I 
touched her belly over her bladder, she winced and shifted a little 
in her sleep. I was surprised that she had only the slightest fever, 
but after reviewing her earlier evaluation and talking with her 
mother, I suspected she was developing a kidney infection and 
needed stronger antibiotics. Belly pain and vomiting are classic 
symptoms of a kidney infection. I didn't call the lob to check on 
her urine culture results because I thought there had been insuffi- 
cient incubation time to yield any useful information. 

I wrote an order for IV antibiotics and fluids and prepared her 
discharge paperwork so the overnight physician would have less 
work to do. When I left the ER, the little girl was still sleeping. 

The next morning, while reviewing our hospital admissions, the 
overnight doctor read a name that sounded familiar. It took me only 
a minute to recognize it as belonging to the four-year-old girl. She 
had been discharged per my order only to return two hours later 
with a high fever and writhing in pain. She was sent by ambulance 



My colleagues arri\'ed within min- 
utes, and together we set about stabi- 
lizing the patient for transport to a 
major burn center more than 300 miles 
away in Phoenix. The nurses miracu- 
lously found veins through the charred 
and peeling skin. The man's mouth and 
upper airway were black and smoky, 
but the breathing tube went in easily. 
The sound of raspy struggles for air was 
replaced with slow, regular breaths 
monitored by a ventilator. 

As I gave a report to the burn center, 
one of the nurses handed me a thick, blue 
chart, so I could provide the patient's 
medical information. I immediately rec- 
ognized the name — Oscar Denetsosie. 
"That's Oscar?" I asked, incredulous. I 
had found him unrecognizable. 

Oscar was in his mid si.xties, dis 
abled by chronic diabetes and high 
blood pressure and blinded by glauco- 
ma. This last detail explained the milky 
blue eyes in a Nawajo man. I had been 
the last staff member to see him in our 

clinic just t\\'0 weeks earlier; my signa- 
ture on the last page of his medical 
chart peered at me eerily. 

zAlthough Oscar li\'ed in what could be 
considered the middle of downtov\'n, his 
home — like those of many elders in our 
community — lacked central heat, elec 
tricity, and running water. He kindled 
his own fire in a wood burning sto\'e 
e\ery day to keep warm. 

"He always built his fire big," his 
niece said that afternoon. "I kept telling 
him to make it smaller, but he always 
said he \\'as too cold. He said he'd been 
building fires his whole life, and he 
liked them big." 

Many clinicians had tried to get 
Oscar a daily aide, but the long term 
care provider in our area had denied 
him services because he could still 
walk. If he was ambulatory, the service 
manager reasoned, he should be able 
to care for himself. We had looked for 
alternatives, but his family had already 
withdrawn him from one nursing home 

because it was more than a hundred 
miles away. On the day of the fire, Oscar 
was on the waiting list for another 
facility, with an admission scheduled 
for the following week. 

In our remote area, access to resources 
is difficult. Nursing homes, sometimes 
hundreds of miles away, create culture 
shock for our traditional elders. Those 
of us working on the rez value the tra- 
ditional ways. But sometimes we forget 
that living without amenities can be a 
reflection of poverty rather than a con 
scious will to preserve an ancient 
lifestyle. Oscar wasn't traditional. He 
was poor. 

When Oscar arrived at the burn 
center, barely alive, the doctors there 
estimated that he had suffered third- 
degree burns over 95 percent of his 
body. In consultation with the burn 
specialists, his family decided to with- 
draw life support. The doctors put him 
on a morphine drip, and Oscar died 
shortly before midnight. ■ 


to a hospital with a surgeon, nearly 80 miles away, where she was 
found to have a burst appendix. Her surgery required o large inci- 
sion with a drain that remained in place afterward to release the 
pus oozing from her abdomen. 

When I heard her ultimate diagnosis, I immediately recognized 
my error. Appendicitis is one of the most commonly missed diag- 

noses in medicine, because its early symptoms mimic those of too 
many other illnesses. For the pediatrician who saw the girl in the 
morning, appendicitis had been her diagnosis to miss. But it had 
been mine to catch. 

A year later, I saw the little girl again, this time for a welkhild 
checkup. In examining her, I found a large welt on her lower 
abdomen. The wide scar, significantly larger than that of an uncom- 
plicated appendectomy, haunted me as I listened to her heart and 
checked her pulses. 

Those of us trained in Western medicine like to think that sci- 
ence confers a certain precision on our efforts. But we are all sus- 
ceptible to moments of human error and blindness. Whether 
practiced by Harvard-trained physicians or by traditional Navajo 
medicine men, healing remains above all an art. Experience 
hones intuition with results that are sometimes brilliant and some- 
times flawed. ■ 

Ellen L Rothman '98 practices medicine with the Indian Health Service 
in northern Arizona on the 'Navajo Reservation. All patient names in 
these essays are pseudonyms. 



Interview by 
Elissa Ely 


A surgeon turns to writing to help dissect the medical profession 


size across his front yard. His parents were dear friends, one a neurologist, 
the other a neuropathologist. I sat down next to him. "What's in the bucket?" 
I asked, aiming to endear myself. ■ "Brains," he replied. "Fm takiri 'em to 
work." ■ We are all the products of our pasts, either agreeably or in direct 
revolt. The little boy became a lovely young man with no interest in 
brains — he wants to be a forest ranger. ■ Atul Gawande '94 is also the son 2 
of two doctors — a urologist father and a pediatrician mother, both of § 
whom immigrated to New York from India to study medicine — and who § 
knows what odd things he dragged through the yards of his childhood? I 



AtuI Gawande has 
combined a career 
in surgery with high- 
profile forays into 
the worlds of politics 
and literature. 

awande can trace his political activist roots to his undergraduate 
days at Stanford, when he stuffed envelopes in support of Gary 
Hart's unsuccessful 1984 presidential bid. 

Last year Gawande finished his final year of residency at 
Brigham and Women's Hospital, where he continues to prac- 
tice surgery. He is now an assistant professor at both HMS 
and the Harvard School of Public Health. A former Rhodes 
scholar, he continues to explore his long-held fascination 
with the intersections between medicine, politics, and ethics. 

Gawande can trace his political acti\ist roots to his under 
graduate days at Stanford, when he stuffed envelopes in sup- 
port of Gary Hart's unsuccessful 1984 presidential bid. In 
1992, he temporarily suspended his studies at HN4S to 
become the social policy advisor in the "war room" of the 
Clinton presidential campaign. Gawande went on to serve as 
a senior advisor at the Department of Health and Human Ser- 
vices for a year before returning to Harvard, where he earned 
both his medical and pubUc health degrees. 

In 1998, following two years of authoring columns for the 
online magazine Slate, Gawande became a staff writer on sci- 
ence and medicine for The New Yorker. He eventuitUy folded his 
essays from those pages into a widely acclaimed book, CompU 
cations: A Surgcori's Notes on an Imperfect Science, pubhshed in 2002. 

The bucket Gawande has dragged — through Harvard and 
Oxford, through medical and pubhc health studies, through 
research and social policy and surgery — is never fuU enough for 
the one dragging it. He is taking his brains, all of them, to work. 

I visited Gawande at Brigham and Women's Hospital recent- 
ly. His office was full of books — Textbook of Endocrine Surgery, 
A Civil Action, The Perfect Storm, a volume of Picasso reproductions. 
There was a photo of President Clinton shaking hands with 
him. A pair of dress pants and a dress shirt were draped over 
a cart in the corner, looking forlorn. They wouldn't be getting 
out on the town anytime soon. His beeper went off 

Ely: When I called at six this morning, M'crcyou writing: 
Gawande: No. By six, I was getting ready to take off for 
rounds. Usually I come in early. It depends on how late I've 
been up the previous night, because I don't like to lose sleep. 
But I sacrifice it if I have to. If I'm working against deadlines, 
I'll set the alarm extra early and come in, that four- 
to-six-in-the-morning slot is the only time when nobody's 
paging me and only rarely is a patient crashing. When I'm off 
on weekends, I do a lot of writing then — Saturday and Sun- 
day mornings, before I take the kids in the afternoons. N4y 
wife is the real secret to how I get stuff done. 

Ely: You wrote in Complications that surgeons can't "dither." 
But writers do. Thcv dither all the time. 

Gawande: We had stretches when I'm just writing. It's miser- 
able. I don't actually get any more done. I'U spend the whole day 
on one sentence instead of the 20 minutes I've allocated for it. 
It doesn't seem to help having extra time to wTite. I have to have 
a basic amount of time, more than I actually have at the 
moment, but I can't vv'rite more than three or four hours a day. 

Ely: Some of your magic is the feeling that you pull your topics from 
a hat: there's a rabbit! There's a hippopotamus! Where do those 
creatures comefrom^ 

Gawande: I guess it's the confidence I have that if I'm interest- 
ed in something, other people will be, too. I think that if we 
can't explain something, it's because we don't understand it. In 
my PalmPilot, I keep a Hst of my ideas for articles, and there's 
more than I can possibly write about. [He pulls out his PalmPilot] 
Let's see, what am I up to? Number 43. Some of them are stu- 
pid — the editor says, "No sale." But some, I think, are cool. 

Ely: What happens to ideas after the PalmPilot stage? 
Gawande: Then it's just foraging around and doing more 
research than I intended to do. I'm working on a piece right 
now for The New Yorker I thought: research in three weeks, 
three more weeks to write it, I'll be done. Two months later, 
I'm still researching. I talk to people and start chasing their 
ideas down. They take you far afield. 

Ely: If seems you're always flying to interview someone in another 
part of the country. 

Gawande: If I'm going to spend one of m)' few free week- 
ends in Minnesota, it's because I know what I need. It's the 
"video," as my editor puts it — you need to offer something 
that readers can visualize. 

Ely: Do other surgeons criticize what you offer for readers to sec? 
Gawande: The criticism that has stung the most has been: 
what right do you have to try to explain medicine when you 
haven't even been part of it for that long? When The New Yorker 
published my piece about the residency learning process, 
the first chapter in my book, several surgeons said, "I can't 
believe you wrote this. It's just going to increase the number 
of patients coming to me asking me to kick the residents 
out of the room." 

That was a concern I had as well — that the emotional and 
rational responses of people reading my pieces would diverge, 
and that wouldn't be good. But when people accuse me of try- 
ing to do expo,ses or say that medicine is bad — those criti- 



cisms don't sting much because those people clearly ha\'en t 
read my book or understood what I'm trying to achieve. 

Ely: But \ou do talk about the elephants in the room. We have all 
wonied about how good our doctors are. for example. We have all 
wondered how well tramed the resident doing a procedure on us is. 
Gawande: That's the thing. Many of the topics I take up are 
ones m the public di,scu.ssion a hundred times over already. I 
don't feel I'm throwing anything out there that people weren't 
already arguing about. I'm just adding my own two cents. 

Ely: Howdoyou decide how to frame the sensitive topicsyou write about! 
Gawande: Whenever I tackle a piece, I just write it the w^ay 
I want to, then we start going through the editing process. 
Then suddenly I realize that it's going to published, and I 
want to start taking things back! So I share my article with 
two people as a litmus test of whether I've gone off the deep 
end: a surgeon \\ith great instincts for how the medical com- 
munity reacts and my wife, a former editor with great 
instincts for how the public will respond. She's a barometer 
for when I seem too cold or inhumane. 

Right before the book came out, I was ner\'0us about 
whether it would be regarded as a helpful effort within the 
profession or an attack. But it was taken as part of an experi 
ence everyone is going through — trying to figure out how to 
deal in this world where medicine is extraordinarily success- 
ful and yet patients don't think doctors are gods an^inore. 
The net response was positi\'e. I've been asked to speak at the 
American College of Surgeons rather than being drummed 
out of it. I ga\'e grand rounds as a resident in more places than 
I should ha\e had a right to. It's made me feel more accepted 
within surgery, where half my reason for writing, I think, was 
that I never quite felt sure I fit into that world. 

But, as it turns out, surgery is more self- analytic, more 
curious, and more open than it used to be. Hidebound con- 
servatism still persists in some element, but many of those 
people feel increasingly left out. Among my generation, you 
have people who are thinking of life in medicine in a very 
different way. 

Ely: Surgeons and doctors who are very human. 
Gawande: Yes — who want to be human and compassionate 
but also want to be just as tough as the next guy when it 
comes to being able to stay up all night or knowing the drug 
doses or being able to hog a tumor nobody else could get out. 

Ely: People seem to respond to you in three ways. The first is, they 
have a sudden interest in topics theyd never thought about before. The 
second is. we feel you feel we're intelligent enough to be grappling with 
these issues like you do. And the third is, because your writing is so 
kind, people become interested inyou, which must be a mixed blessing. 
You appeal to our humaneness, but does it come back to bite you'? 
When vou have a bad day and snap at a patient, is he shocked! 
Gawande: It's true, I feel like I have to be on m)' best behavior 
.\11 the tmic. I can't have a shp. But e\'erybody does shp — so 
I'm embarrassed sometimes. The person you present when 
you're writing is always your best \'ersion of yourself. I edit 
out the parts where I seem like a jerk. 

Ely: If'.s easy to romanticize all you do. What's the price you pay! 
Gawande: Oh, it's not a romantic life. It's painful. It creates a 
constant low level anxiety — that's the internal cost. The 
external cost is, I ha\'e to make choices. I don't get to see my 
wife and kids as much as I want to. What comes first is 
surgery What comes second is writing. Well, really what 
comes first is family — but how can you objectively claim they 
come first, when I'm here all day and everything else is fitting 
around the edges? Each day I try to figure out my priorities, 
so my family isn't totally forgotten, but that's definitely the 
high cost. So far, I've tried to make it all work. 

Eventually I can't do research at the School of Pubhc Health 
level and surgery at the Medical School le\'el and writing at 
The New Yorker level. Eventually I'll have to figure out how to 
corral that. What makes it exciting — and makes the writing 
work — is that I have the other balls in the air. Surgery gives 
me an exposure and a way of testing myself I wouldn't other- 
wise ha\'e — and it's a reality check. Research keeps me in a 
community of people thinking about more than just the 
patient you ha\'e in front of you that day. 

Ely. All the balls are in the air 

Gawande: But they'll come down. The interesting thing is, 
something totally different could become the one ball left in 
the air. When I started down this road, I was a guy who had 
come out of poUtics, worked for Clinton, began writing 
because ! was interested in pohcy and didn't know another 
way to stay abreast of ideas. Then it e\'oh'ed into something 
else. Next thing you know, here I am — and not e\'en thinking 
of politics very much. And it's been only seven years since I 
picked up the pen! ■ 

Elissa Ely W is a lecturer on psychiatry at HMS. 




ne of Harvard Medical Schoors 
more formidable surgeons, Elliott 
Cutler '13, was also among its more 
lighthearted and engaging teachers. 
He once told my class a story about the leg- 
endary neurosurgeon Harvey Gushing, Class of 1895, who 
used to travel to the Peter Bent Brigham Hospital every day 
in a chauffeured limousine. As Cushing rode, his little terrier 
would trot along behind the car. It was the chauffeur's 

habit to keep an eye on the dog in the rearview mirror. After traveling a moderate distance, the 
chauffeur would notice that the dog had collapsed on the road, struggling to catch its breath. The 
chauffeur would stop the car, grab the pup by its front legs, and shake it \'igorously. The dog 
would return to form, then continue its determined chase. The chauffeur would drive on for 
another piece and the entire sequence of e^•ents would repeat. ■ After relating this anecdote to our 
class. Cutler posed a question: "What was wrong with the dog?" We were flummoxed, of course, 
and remained silent. Dogs who chase cars tend to get run over. Cutler reminded us, and when 
they're run over, their diaphragms tend to rupture. Thus it was logical to deduce that the exer- 
tion of running forced the intestines of the poor dog through the rupture into the chest cavity 
with resultant respiratory distress. The chauffeur had been astute enough to grab the pooch by the 
forelegs and shake its intestines back dowTi into the abdominal cavity where they belonged. ■ 



Ice Capade 


In one of our earliest classes at the Peter Bent 
Brigham Hospital, we neophytes were 
taught the rudiments of percussion in phys- 
ical diagnosis. The professor summoned one 
prominent student from the stands and 
asked him to percuss the left heart border of 
the bare-chested patient in the arena. With 
unwavering aplomb, our classmate tapped 
his fingers on the maris chest before making, 
with quick flourishes of his red-wax pencil, 
a slanting series of "X" marks down the 
patient's left chest. Just imagine the chagrin 
of this sacrificial lamb, however, when the 
projected x-ray re\'ealed that the patient had 
dextrocardia — a rare, inherited condition in 
which the heart is located on the right side of 
the body instead of the left. Such dirty tricks 
were designed to keep us medical students 
on our toes, not resting on our laurels. ■ 

Within a few days of signing on with the Army Medical 
Corps in 1942, I was dispatched to Cuba. There, not 
long after my arrival, an American bulldozer operator 
presented himself at our dispensary seeking treatment for the after- 
math of a weeklong spree of inebriation in Havana. Tests revealed 
that the patient was suffering from not one, but three venereal dis- 
eases: the chancre of primary syphilis, acute gonorrhea, and chan- 
croid. Such a trifecta of infections indeed called for extraordinary 
therapeutic measures. 

My thoughts drifted back to my hIMS days when I worked as a 
lob technician at the Boston Psychopathic Hospital with my roommate, 
Fred Bartter, whose 1962 observations of a kidney disorder led to its 
naming as Bortter's syndrome. I recalled the use there of so-called 
fever cabinets to treat "general paresis of the insane," a manifestation 
of tertiary syphilis. Before the advent of antibiotics, it was common to 
induce very high fevers to treat infections. 

Accordingly, I gave the patient on intravenous injection of typhoid 
vaccine, which boosted his temperature to 105 degrees. Then we 
mmersed him in a tub of ice water. It certainly couldn't have been 
pleasant for the patient but it worked: his venereal diseases were 
all successfully overcome. ■ 




One evening about thirty years ago, as I was 
about to leave my internal medicine practice in 
Holyoke for supper with my wife and children, 
a neighbor called. "Sam, I hate to bother you," 
he said, "but could you stop b\' on your way 
home? My wife's not feeUng well." 

When I arrived, I was alarmed to hear 
Mrs. P., a woman in her mid fifties, complain 
ing of unsteadiness on her feet, blurred vision, 
and "a funny feeling" in the back of her head. 
My well-stocked medical bag was replete 
with diagnostic equipment; it even had small 
bottles of cinnamon and cloves to test the 
patient's sense of smell. 

After conducting a thorough neurological 
examination, I had no choice but to tell the 
patient, "Mrs. P., I think you have a brain tumor 
and I'm sending you to the best neurosurgeon 
in Boston." There surgeons resected a four- cen- 
timeter benign meningioma from the occipital 
area and the patient made a complete recovery. 

My fee for the house call was ten dollars. ■ 

You Say Potato 

During our senior year at Boston City Hospital, 
Irving "Ike" Walker was conducting a surgical 
conference in a large auditorium. The audience 
consisted not only of us medical students, but also 
interns, residents, local doctors, and physicians visiting 
from afar. 

While describing a surgical case. Walker recounted, 
"And then we put the patient in the Tren-DEL-enburg posi- 
tion." This position — in which the patient is placed on on 
inclined plane, with the head down and legs and feet 
over the edge of the table — is often used to treat shock 
or, in abdominal operations, to push abdominal organs 
toward the chest. 

A meek voice from the back row piped up, "TREND- 

Clearly irritated. Walker firmly repeated, "We put the 
patient in the Tren-DEL-enburg position." 

Again, the meek voice from the back row insisted, 

Now obviously irate, Walker shouted, "Who's mock- 
ing me bock there?" 

The same voice, no longer sounding meek, thundered 
in response, "I'm TRENDELENBURG!" The son of the 
famous German surgeon, himself a doctor, happened to 
be attending the conference that day. ■ 




One Sunday afternoon, a fellow Rotarian 
invited me to his home to view slides of 
a recent trip to Europe. During the 
slideshow, his wife sat drowsily nearby, 
wrapped in a large shawl despite the 
warmth of the room. Noting with concern 
her expressionless face, her general list- 
lessness, and the loss of hair on the lateral 
portion of her eyebrows, I asked her a few- 

After hearing her sluggish answers, 
I concluded that she had classical myxede- 
ma, a disorder caused by extreme hypo- 
thyroidism. I had my portable EKG 
machine in my car, and I suggested run- 
ning a tracing on her. 

"Absolutely not!" she cried. "Doctors 
terrify me and I can't stand needles!" 

I reassured her that she had nothing to 
fear, then ran an EKG tracing that revealed 
not only bradycardia, but also low-ampli 
tude waves — e\'idence that seemed to sup- 
port my suspicion. 

Accordingly, I started her, rather gingerly, 
on a course of thyroid replacement and in a 
matter of weeks she was remarkably healthy. 
The success of her therapeutic regimen was 
e\idenced by the world tour she made with 
her husband the following year. ■ 

During my first year at HMS, four of us shared a room on 
the fourth floor of Vanderbilt hiall, with windows overlook- 
ing the tennis court below. The school year was barely 
under way when, one afternoon, our next-door neighbor knocked 
on the door with an unusual request: he had forgotten his key, and 
would we permit him to exit our window? It didn't occur to any of 
us young future doctors that this might be a bod idea. 

We watched with interest as our neighbor squeezed his frame 
through the small window opening and then inched his way 
along the narrow ledge, his heels dangling in the air. When his 
traverse finally brought him to the open window of his own room, 
he slipped inside and turned to wave his thanks. 

Little did we realize at the time that our neighbor was none 
other than T. Duckett Jones, destined for a distinguished medical 
career; had he plunged to his doom that day, the world would 
have been deprived of what became known as the Jones Criteria 
for diagnosing acute rheumatic fever. ■ 






After my stint in Cuba during World 
War II, the Army Medical Corps dispatched 
me to British Columbia, where I undertook 
an assignment at Camp Canol on the 
Mackenzie Ri\er, just below the Arctic 
Circle. I e\'entually received a certificate 
proclaiming me the highest ranking U.S. 
Army medical officer between the Yukon 
Territories and Hudson Bay. 

Our mission at Camp Canol — short for 
Canadian OU — was to construct a pipeline 
that would pump crude oil from the eastern 
shore of the Mackenzie Ri\'er to White- 
horse in the Yukon. There, a three and a- 
half- million' dollar refinery would convert 
the crude into high-octane airplane fuel. 

Many of the pipeline workmen had pre- 
viously served on construction jobs in the 
tropics. So I wasn't surprised when one of 
the workers presented himself at the infir- 
mary with a stool specimen that contained 
a rectangular, ribbon like bit. When I 
studied its characteristics, I realized that it 
was a proglottid segment of Taenia solium — 
the pork tapeworm. 

I sent a wireless message to Edmonton, 
Alberta, requesting oleoresin of aspidium. 
When a single capsule of the drug arrived, 
we gave it to the patient with a generous 
dosage of milk of magnesia and mineral 
oil. We didn't have long to wait before the 
patient passed an 18 foot long tapeworm 
into the bedpan, complete with its pincer- 
like scolex. ■ 

The Undiluted Truth 

While I was at the Camp Canol Dispensary dur- 
ing World War II, I delivered the baby of a 
young Native woman and her husband, a 
vs^orkman from Connecticut. The infant flourished, but the 
woman developed life-threatening streptococcal tonsillitis. 
Against Army regulation, I admitted her to the dispensary 
and hid her behind some folded screens. 

The next day, a colonel visiting from Walter Reed Army 
Hospital decided to make medical rounds and demanded to 
know whom I had sequestered behind the screens. On hearing 
the story he said, "Captain, get on the wireless to Whitehorse 
and have them fly over some of that new stuff, penicillin." 
Before Whitehorse could act, though, an Arctic storm 
blew in, and planes were grounded for three days. When 
the weather cleared, a plane flew over our base and para- 
chuted down three vials of Pfizer's golden penicillin, at 
100,000 units per vial. 

I instructed the nurse to dilute one of the viols with lOcc 
of sterile normal saline and give the patient a Ice injection 
every three hours. Yet the nurse inadvertently administered 
the contents of on entire viol, a dose ten times what I hod 
ordered. Miraculously, the patient recovered and ended up 
naming her son after me. ■ 

Samuel Potsubay '40, a retired internist, practiced in Holyoke, Massachusetts, 
for 42ycars. He can he reached at sampotsuhay& 



GANGSTER WRAP: Early kidney transplant 
recipient Joe Palazola was taken into police 
custody when the surgical mask he wore to 
prevent infection aroused a state trooper's 
suspicion that he was a bonk robber fleeing 
a heist. Palazola's surgery extended his life 
years beyond the conventional expectations 
of the times. 

Harvard's Surgical Research Laboratory has closed its doors after nearly a 
century of advances that have boldly transformed the v/ay medicine operates 




duty at Boston's Peter Bent Brigham Hospital assured 
the police officer on the other end of the telephone that 
he was indeed familiar v\dth Joe Palazola. But what was 
the call about? Palazola, the officer responded, had just 
been arrested as a suspected bank robber. A passing 
state trooper had spotted him in his car wearing a mask 
and a porkpie hat tipped low over his eyes. The trooper 
had pulled him over and then hauled him off to the 
pohce station. ■ The surgery resident protested that 
Palazola was receiving powerful immunosuppressive 
drugs to prevent rejection of a kidney just trans- 
planted at the Brigham, and that he was wearing a 
surgical mask to ward off potential infection. 
Despite the explanation, the officer demanded that 


the patient's physicians go down to the station to post bail. 
The following day, a picture of the suspect flanked by burly 
policemen made its way into a local newspaper. 

Despite his vulnerability to infection — and arrest — 
Palazola's new kidney functioned promptly, without signifi 
cant rejection, transforming him from a person dying of irre 
versible, end-stage disease into someone essentially healthy. 
He — and thousands of others like him in need of bold exper- 
imental approaches to life-threatening illnesses — might 
never ha\'e recei\'ed a second lease on life had it not been for 
the extraordinary innovations that took place in the only lab- 
oratory of a chnical department based on the Quadrangle of 
Harvard Medical School. 

Now, 40 years after Palazola's altercation with the law 
and 92 years after its founding, the Surgical Research Labo- 
ratory, one of the most famous of its kind in the world, has 
closed its doors. This closure comes as a result of such 
forces as the School's need for office space, the reorganiza- 
tion of experimental laboratories at Brigham and Women's 
Hospital, changing priorities in surgical research, and a lack 
of funding for investigators whose efforts are increasingly 
limited by the exigencies of patient care and the economic 
demands of medicine. 

The Crucible 

Harvey Gushing, Class of 1895, could only ha\'e dreamed of the 
breakthroughs to come when he founded the Surgical Research 
Laboratory in 1912. As the first surgeon-in chief at the Peter 
Bent Brigham Hospital and the Moseley Professor of Surgery 
at HMS, he stipulated that he be given laboratory space on 
the Quadrangle to study surgical science in animal models 
and to introduce medical students to the discipline. 

Cushing's approach departed from established traditions 
in the United States at a time when students were primari- 
ly spectators and investigative activity took low priority. 
Upon his arrival at HMS, he and his colleagues immediately 
set to work. His study of the relationship between the pitu 
itary gland and carbohydrate metabolism led to a collabora 
tion with one of his HMS classmates, Elliott Joslin, in exam 
ining the high incidence of diabetes in acromegalic patients. 

One of Cushing's colleagues, Lawrence Weed, defined the 
circulation of the cerebrospinal fluid. Emile Goetsch de\'ised 
the adrenalin test for patients with hypothyroidism. And 
Emil Holman performed conclusive experiments on the 
physiology of arterio\enous fistula. This early producti\it)' 

quickly proved to those remaining skeptics the benefits of a 
surgical laboratory with strong ties to a clinical service. 

Cushing's laboratory allowed his trainees to answer clini 
cal questions in animal models. One pressing and unmet need 
was the abiht)' to transfuse blood safely. Carl Walter '32 never 
forgot what he described as a "spectacular misad\'enture" in 
his fourth year at HMS. While attempting to transfuse one of 
Cushing's patients during surgery by direct transfer from an 
adjacent donor, Walter was disconcerted when the pump he 
was using suddenly imploded \\ith a tremendous spattering 
of its contents. "Jesus Christ!" the startled Walter exclaimed, 
"there has to be a better way!" "Whoever said that, come to my 
office after surgery," Gushing quietly commanded. 

When Walter arri\'ed, he found Gushing furious that any 
one would dare to curse in his operating room. .After the pro- 
fessor pressed Walter to admit that he didn't know of a better 
technique for transfusion, he exhorted the younger man to 
find one. Working in the laboratory, Walter went on to create 
the plastic blood bag, disposable intra\-enous tubing, and 
improved methods of blood preser\'ation. 

The Cutler Edge 

Elliott Cutler '13 succeeded Gushing as surgeon-in-chief at the 
Brigham in 1932. Unlike his dour, single-minded predecessor. 
Cutler was enthusiastic and effervescent. Although he consid- 
ered himself a true general surgeon — as comfortable perform- 
ing complex neurosurgical procedures as he was operating in 
the thorax or abdomen — he had become increasingly inter- 
ested in the possibihties of heart surgery on human patients, 
a prospect that had long elicited resistance from surgeons. 

With Brioham cardiologist Samuel Le\ine '14 and resident 
Claude Beck, Cutler initiated experiments to alle\iate mitral 
stenosis. After extensi\'e testing in dogs, in 1923 Cutler 
became the first to operate upon a human patient with the 
condition. She recovered and li\'ed asymptomatically for 
seven years before recurrent stenosis pro\'ed fatal. 

Haxing sur\i\ed Cushing's wrath, Carl Walter trained 
under Cutler and became an important in\estigator and 
teacher in the Surgical Research Laboratory during the 1930s 
and 1940s. In addition to his work on blood banking technolo- 
gies, his inno\'ations included the de\'elopment of operating 
room sterihzers \'asdy superior to those then available, a ther- 
mostat so effective that it is still often used in commercial 
jet engines, and — in collaboration with John Merrill '42 — 
dramatic improvements to the hemodialysis machine. 



For years, Walter directed the Course in Aseptic Technique 
to introduce Har\'ard medical students to surgery and to teach 
standardized operating practices. Each week, a team of four 
students would perform operations of increasing complexity 
on dogs. The instructors — Brigham staff surgeons, ane.sthesiol- 
ogists, and nurses — stressed effective scrubbing techniques, 
understanding one's role in the operating room, careful record 
keeping, and postoperative care. During World War II, the 
course expanded to include community surgeons about to 
enter the conflict; in many cases the course pro\'ided the only 
surgical training they received. 

Walter's instructional methods were exacting and some- 
times painful. If a medical student was bending too far over 
the operati\'e field, for example, he could expect a sharp blow 
on his back. Walter taught students to scrub properly by cov 
ering their hands with lamp black; he then blindfolded them 
and challenged them to get their hands clean. Finding their 
best efforts inadequate, he would send them back to the sink 
again and again. After their hands were scrubbed to his satis- 
faction, Walter would casually drop a quarter on the floor and 
then chastise the unwitting victims for their instinctive 
retrie\'al of the coin. They ne\'er forgot his lessons. 

Windfall of War 

When Cuder and many of his staff left to serve during World 
War II, a handful of imaginative investigators carried on the lab- 
orator)''s work. Their contributions would prove significant in 
the histor)' of modern surgery As a resident, Robert Gross '31 
had considered the possibilities of correcting congenital cardiac 
defects in children, particularly of the great vessels. After work- 
ing out operati\'e approaches to the heart and great vessels in 
dogs, in 1938 he became the first to ligate successfully the 
patent ductus of a young patient. Then, with surgical resi- 
dent Charles Hufnagel "41, he refined techniques of vascular 
anastomosis to correct coarctation of the aorta and other 
developmental anomaUes. 

To tackle the problem of aortic insufficiency, Hufnagel 
designed ball val\'es housed in rigid prostheses and affixed 
them in the thoracic aortas of dogs. This innovation, later used 
in human patients, also led to the caged ball valve now in use. 

At the same time, Da\'id Hume defined in dogs the hypo- 
thalamic control of the pituitary gland and the endocrine 
changes that occur with stress. His early data on the 
endocrine -metaboUc responses to injury enhanced the later 
studies of Francis Moore '39. 



CAR! W WAITER m:ma. 

CLUB: Pioneers in the 
Surgical Research Labo- 
ratory, clockwise, from 
upper left: Elliott Cutler; 
Robert Gross with an 
early cardiopulmonary 
bypass machine; urolo- 
gist J. Hartwell Harrison, 
nephrologist John Mer- 
rill, and surgeon Joseph 
Murray, who together 
collaborated on the first 
organ transplant in 
humans; Harvey Cushing 
with a young patient; 
Carl Walter displaying 
his newly designed 
blood bag; and Mono, 
one of Murray's early 
immunosuppressed kid- 
ney allograft recipients, 
shown >vith her puppies 
and an animal handler. 



Moore was appointed the Moseley Professor in 1948, a year 
after Cutler's death. Moore's fascination with treatments for 
burn injuries stemmed from his experience wdth the victims of 
the Cocoanut Grove nightclub fire six years earlier. As one of 
the earUest investigators to use the newly available radioiso- 
topes in humans, he spent much of his subsequent career 
defining body composition and the dynamic shifts of fluid, 
electrolytes, and body cell mass that occur with surgical injury 
and convalescence. Investigations in animals confirmed and 
broadened his clinical determinations. 

The laboratory flourished under Moore's leadership, with 
se\'eral members of his staff exploiting postwar inno\'ations. 
One involved heart surgery. Dvvight Harken '36 had gained a 
significant reputation during the war by removing bullets and 
pieces of shrapnel from the hearts and great vessels of soldiers 
without losing a single patient. Based on animal experiments, 
he explored the possibihties of treating valvular disease in 
human patients. As one of three surgeons at the time to con- 
sider the operative relief of mitral stenosis, Harken developed 
a technique of fracturing the fused \'alves with his finger 
placed through the left auricular appendage. He performed 
this mitral valvuloplasty in more than a thousand patients, 
with ever- improving results. 

A pioneer in the field of heart surgery, Harken also designed 
caged ball prostheses to fit in anatomic position in the aortic 
root of dogs. Then, in 1960, he became the first to place one in 
a patient with aortic insufficiency. His subsequent achieve- 
ments in the laboratory included the creation of the direct cur- 
rent defibrillator, the concept of counterpulsation, and the 
development of a variety of cardiopuhnonary bypass devices. 

It was also during this era that the transplantation research 
leading to Joe Palazola's arrest took off. Against the advice of 
some of his colleagues, Joseph Murray '43B transplanted a kid 
ney from one identical twin to the other in 1954. It was an 
unprecedented success. Kidney transplantation had been an 
interest at the Brigham since 1947, when a kidney from a 
cadaver had been used as a bridge to support a young woman 

dying of renal failure, and Hume had transplanted renal allo- 
grafts into nine immunologically unmodified hosts. Murray 
refined the operation in dogs so effectix'ely that the technique 
has become the universal standard in human patients. 

Engraftment between genetically disparate donor-recipi- 
ent pairs proved more challenging. In the 1950s, work at the 
laboratory and elsewhere led to the use of total body radiation 
as the only a\'ailable method to suppress the immune barrier, 
as shown by prolonged graft surxiv'al in radiated animals. The 
survival of an occasional human kidney recipient encouraged 
the few teams involved in transplantation to continue. 

In 1960, a young English research fellow, Roy Calne, 
brought the first effective chemical immunosuppression to 
Murray's laboratory. The new treatment soon sustained some 
canine kidney recipients in a healthy state over weeks or 
months. The drug, azathioprine, produced comparable 
results in patients and became the linchpin of immunosup- 
pressive therapy for many years. Murray's receipt of the Nobel 
Prize in 1990 recognized his pioneering w^ork in the field. 

A Collaborative Era 

During subsequent decades investigators in the laboratory 
increasingly took advantage of new treatments and technolo- 
gies in chnically apphcable animal models. The Course in Asep- 
tic Technique, which we organized and taught along with John 
Rowbotham '46, flourished, drawing many students to surger)^. 
Excessive costs and pressures from the anti\i\isectionist mov'e- 
ment, however, led us to suspend the course in 1986. 

But significant innovations at the laboratory continued. 
A Brigham surgical resident, Robert Bartlett, working at Chil- 
dren's Hospital with Robert Gross, had become increasingly 
interested in infants and children who developed progressive 
and fatal pulmonary insufficiency following prolonged opera- 
tions. Together with Phihp Drinker, an engineer in Moore's 
department, Bartlett conceived of an "artificial lung" that 
could .support these patients through the critical postopera- 

The Shock of His Life 

uring the early 1960s, 
the standard means of 
determining whether a 
renal transplant was 
functioning was to per- 
form an intravenous 
pyelogram — a test in 
which a radio-opaque dye, injected intra- 
venously, would be excreted by the working 
kidney and visualized by sequential x-rays. 
The Surgical Research Laboratory had an 
old, temperamental x-ray machine available 

for such studies. One day while using the 
machine a young staff surgeon working in 
the laboratory, Nathan Couch '54, suddenly 
collapsed, pulseless. The x-ray machine had 
emitted an electrical shock that had run 
through his body to the floor. The surgical 
technician on hand desperately called the 
hospital for help. In the meantime, he and 
the research fellows opened Couch's chest 
with the only surgical instruments immediate- 
ly available — canine ones — and began to 
massage the young man's heart. Once his 

heart restarted, they sewed him up and 
transported him to the nearby intensive care 
unit at the Peter Bent Brigham Hospital. 

For 14 hours Couch Icy in a coma so 
deep that a diagnosis of brain death was 
considered. Miraculously, however, he 
gradually revived and went on to enjoy a 
distinguished surgical career. The charred 
hole in the sole of one of his shoes and a 
burned patch of linoleum on the laboratory 
floor attested to the severity of the electrical 
discharge that had nearly killed him. ■ 



ONCE AND FUTURE KINGS: Surgical staff from the Peter Bent Brigham Hospital offered the Course in Aseptic Technique to 
Harvard medical students. Above, Elliott Cutler and Carl Walter supervise a surgical procedure on one table, while Francis 
Moore (far left), then a student, administers open-drop ether anesthesia to a canine patient on the other. 

tive period. Extracorporeal membrane oxygenation, or ECMO, 
first used successfully in an anoxic patient in 1971, has sub 
sequently saved the lives of thousands of children. 

John Mannick '53, a productive surgeon scientist who 
succeeded Moore as surgeon-in-chief of the Brigham in 1976, 
fostered a receptive environment for research. Among his 
colleagues in the laboratory was John Collins, who had 
succeeded Harken as chief of cardiac surgery at the Brigham. 
Colhns designed experimental models to impro\'e substan 
tially the safety of valve replacements and the effecti\'eness of 
cardiopulmonary bypass. His early use of the internal tho- 
racic artery in dogs to direct more blood to heart muscle was 
quickly brought to chnical use in humans. 

Another colleague, Lawrence Cohn, studied the effects of 
ischemia-reperfusion and other cardiac injuries in large ani- 
mal models. Richard Wilson focused on forms of host toler- 
ance. And Herbert Hechtman '60 examined in detail the 
local effects of ischemia reperfusion of the gut and hind 
limb, as well as the influence of resultant circulating 
inflammatory mediators at distant sites in the body. 

Surgical investigators applied new discoveries in cellu- 
lar and molecular biology to study host responses. During 
our three decades in the laboratory, we used these new 
tools to examine the biology of allograft rejection in rat 
recipients of heart and kidney transplants. We built up a 
picture of the acute rejection cascade, defining the dynam- 
ics of T lymphocytes and the interrelationship of cyto- 
kines, chemokines, and their receptors occurring both 
within the graft and in the host. In recent years, we stud- 
ied chronic rejection, noting the process to be primarily 

macrophage-mediated and triggered by a series of antigen- 
independent events, particularly injuries to the organ sec- 
ondary to donor brain death and the period of ischemia- 
reperfusion occurring with transplantation. 

Staged Exit 

Despite the consistent productivity of investigators in the 
Surgical Research Laboratory during its nine decades of exis- 
tence, external demands have been substantially redirecting 
the priorities of academic surgeons. Discouraged about the 
prospects of extramural funding for their studies and unable 
to visualize career advantages to spending time at the bench, 
residents and junior faculty more often invest their creative 
energies in outcomes research, clinical trials, and manage- 
ment training. Most find they must restrict their activities to 
ever more time-consuming clinical work. 

Even so, it seems crucial that a few academic surgeons be 
encouraged to become involved in the basic sciences. This 
small coterie of surgeon- scientists could continue to pio- 
neer ways to salvage or replace damaged organs through 
genetic engineering, artificial replacements, and transplan- 
tation. But with the closure of Harvard's Surgical Research 
Laboratory this spring, their experiments must be con- 
ducted elsewhere. ■ 

Nicholas L Tihcy, MD, is the Francis D. Moore Professor of Surgery at 
HMS. He directed the Surgical Research Lahoratorx from 1975 until 
2001. Mary Graves Tilney the long-time laboratory coordinator, orga- 
nized the Course in Aseptic Technique. 





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